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Background and Purpose: ResolutionMD mobile application runs on a Smartphone and affords vascular neurologists access to radiological images of patients with stroke from remote sites in the context of a telemedicine evaluation. Although reliability studies using this technology have been conducted in a controlled environment, this study is the first to incorporate it into a real-world hub and spoke telestroke network. The study objective was to assess the level of agreement of brain CT scan interpretation in a telestroke network between hub vascular neurologists using ResolutionMD, spoke radiologists using a Picture Archiving and Communications System, and independent adjudicators., Methods: Fifty-three patients with stroke at the spoke hospital consented to receive a telemedicine consultation and participate in a registry. Each CT was evaluated by a hub vascular neurologist, a spoke radiologist, and by blinded telestroke adjudicators, and agreement over clinically important radiological features was calculated., Results: Agreement (κ and 95% CI) between hub vascular neurologists using ResolutionMD and (1) the spoke radiologist; and (2) independent adjudicators, respectively, were: identification of intracranial hemorrhage 1.0 (0.92-1.0), 1.0 (0.93-1.0), neoplasm 1.0 (0.92-1.0), 1.0 (0.93-1.0), any radiological contraindication to thrombolysis 1.0 (0.92-1.0), 0.85 (0.65-1.0), early ischemic changes 0.62 (0.28-0.96), 0.58 (0.30-0.86), and hyperdense artery sign 0.40 (0.01-0.80), 0.44 (0.06-0.81)., Conclusions: CT head interpretations of telestroke network patients by vascular neurologists using ResolutionMD on Smartphones were in excellent agreement with interpretations by spoke radiologists using a Picture Archiving and Communications System and those of independent telestroke adjudicators using a desktop viewer., Clinical Trial Registration Information: www.clinicaltrials.gov unique identifier NCT00829361.

Background and Purpose: The American Stroke Association guidelines emphasized the need for further high-quality studies that assess agreement by radiologists and nonradiologists engaged in emergency telestroke assessments and decision-making. Therefore, the objective of this study was to determine the level of agreement of baseline brain CT scan interpretations of patients with acute stroke presenting to telestroke spoke hospitals between central reading committee neuroradiologists and each of 2 groups, spoke hospital radiologists and hub hospital vascular neurologists (telestrokologists)., Methods: The Stroke Team Remote Evaluation Using a Digital Observation Camera Arizona trial was a prospective, urban single-hub, rural 2-spoke, randomized, blinded, controlled trial of a 2-way, site-independent, audiovisual telemedicine and teleradiology system designed for remote evaluation of adult patients with acute stroke versus telephone consultation to assess eligibility for treatment with intravenous thrombolysis. In the telemedicine arm, the subjects' CT scans were interpreted by the hub telestrokologist and in the telephone arm by the spoke radiologist. All subjects' CT scans were subsequently interpreted centrally, independently, and blindly by 2 hub neuroradiologists. The primary CT outcome was determination of a CT-based contraindication to thrombolytic treatment. Kappa statistics and exact agreement rates were used to analyze interobserver agreement., Results: Fifty-four subjects underwent random assignment. The overall agreement for the presence of radiological contraindications to thrombolysis was excellent (0.91) and did not differ substantially between the hub telestrokologist to neuroradiologist and spoke radiologist to neuroradiologist (0.92 and 0.89, respectively)., Conclusions: In the context of a telestroke network designed to assess patients with acute stroke syndromes, agreement over the presence or absence of radiological contraindications to thrombolysis was excellent whether the comparisons were between a telestrokologist and neuroradiologist or between spoke radiologist and neuroradiologist., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00623350.

Background: Resuscitation centers may improve patient outcomes by achieving sufficient experience in post-resuscitation care. We analyzed the relationship between survival and hospital volume among patients suffering out-of-hospital cardiac arrest (OHCA)., Methods: This prospective cohort investigation collected data from the Cardiac Arrest Registry to Enhance Survival database from 10/1/05 to 12/31/09. Primary outcome was survival to discharge. Hospital characteristics were obtained via 2005 American Hospital Association Survey. A hospital's use of hypothermia was obtained via direct survey. To adjust for hospital- and patient-level variation, multilevel, hierarchical logistic regression was performed. Hospital volume was modeled as a categorical (OHCA/year≤10, 11-39, ≥40) variable. A stratified analysis evaluating those with ventricular fibrillation or pulseless ventricular tachycardia (VF/VT) was also performed., Results: The cohort included 4125 patients transported by EMS to 155 hospitals in 16 states. Overall survival to hospital discharge was 35% among those admitted to the hospital. Individual hospital rates of survival varied widely (0-100%). Unadjusted survival did not differ between the 3 hospital groups (36% for ≤10 OHCA/year, 35% for 11-39, and 36% for ≥40; p=0.75). After multilevel adjustment, differences in survival across the groups were not statistically significant. Compared to patients at hospitals with ≤10 OHCA/year, adjusted OR for survival was 1.04 (CI(95) 0.83-1.28) among 11-39 annual volume and 0.97 (CI(95) 0.73-1.30) among the ≥40 volume hospitals. Among patients presenting with VF/VT, no difference in survival was identified between the hospital groups., Conclusion: Survival varied substantially across hospitals. However, hospital OHCA volume was not associated with likelihood of survival. Additional efforts are required to determine what hospital characteristics might account for the variability observed in OHCA hospital outcomes., (Published by Elsevier Ireland Ltd.)

Background: Recent emphasis on high quality prehospital cardiopulmonary resuscitation has resulted in more out-of-hospital cardiac arrest victims surviving to the emergency department. As such, standardized in-hospital post-cardiac arrest care is necessary to assure optimal neurological recovery. Although therapeutic hypothermia has arisen as a key component in the post-cardiac arrest care paradigm, its interaction with other therapies remains poorly defined., Objective: The purpose of this communication is to demonstrate a potential interaction between therapeutic hypothermia and routinely administered resuscitation medications., Case Report: We present a case of idiopathic ventricular fibrillation in a previously healthy 36-year-old man who developed persistent ventricular fibrillation in the setting of mild therapeutic hypothermia and high doses of routine resuscitation medications., Conclusion: This case illustrates the importance of understanding the potential interaction between therapeutic hypothermia and resuscitation medications along with the need for a systematic and standardized, multi-disciplinary approach to post-cardiac arrest care., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose of Review: Early bystander cardiopulmonary resuscitation (CPR) provides a vital bridge after collapse from cardiac arrest until defibrillation can be performed. However, due to multiple barriers and despite large-scale public CPR training, this life-saving therapy is still not rendered in a majority of cardiac arrest events. As a result, cardiac arrest survival remains very low in most communities., Recent Findings: Several large-scale studies have shown the benefits of dispatch-assisted CPR. These studies have confirmed that on-going dispatch-assisted CPR programs that use a simplified and abbreviated set of standardized questions can hasten the recognition of cardiac arrest. Dispatchers can also utilize strategies to help bystanders overcome the obstacles to beginning CPR. In some communities, dispatch-assisted CPR accounts for up to half of all bystander CPR. Dispatch-assisted CPR programs combined with large-scale public CPR training may be what is needed to elevate CPR rates and survival from out-of-hospital cardiac arrest nationally., Summary: This review focuses on the rationale and evolving science behind dispatch CPR instructions, as well as some best practices for implementing and measuring dispatch-assisted CPR with the goal of maximizing its potential to save lives from sudden cardiac arrest.

Background: Bystander cardiopulmonary resuscitation (CPR) is a crucial therapy for sudden cardiac arrest (SCA), yet rates of bystander CPR are low. This is especially the case for SCA occurring in the home setting, as family members of at-risk patients are often not CPR trained., Objective: To evaluate the feasibility of a novel hospital-based CPR education program targeted to family members of patients at increased risk for SCA., Design: Prospective, multicenter, cohort study., Setting: Inpatient wards at 3 hospitals., Subjects: Family members of inpatients admitted with cardiac-related diagnoses., Measurements and Results: Family members were offered CPR training via a proctored video-self instruction (VSI) program. After training, CPR skills and participant perspectives regarding their training experience were assessed. Surveys were conducted one month postdischarge to measure the rate of "secondary training" of other individuals by enrolled family members. At the 3 study sites, 756 subjects were offered CPR instruction; 280 agreed to training and 136 underwent instruction using the VSI program. Of these, 78 of 136 (57%) had no previous CPR training. After training, chest compression performance was generally adequate (mean compression rate 90 ± 26/minute, mean depth 37 ± 12 mm). At 1 month, 57 of 122 (47%) of subjects performed secondary training for friends or family members, with a calculated mean of 2.1 persons trained per kit distributed., Conclusions: The hospital setting offers a unique "point of capture" to provide CPR instruction to an important, undertrained population in contact with at-risk individuals., (Copyright © 2010 Society of Hospital Medicine.)

In the last decade, many regionalized centers for the care of post-cardiac arrest patients (cardiac arrest centers) have all independently developed with a common goal of providing multi-disciplinary and organized care plans for this patient population. The American Heart Association recently issued support for regionalized and organized comprehensive care for post-arrest patients through a position paper as well as the 2010 American Heart Association BLS/ACLS guidelines. This paper outlines the formation, structure, and implementation of four cardiac arrest centers, and also discusses a statewide model of post-arrest center care. This paper may assist other potential clinical sites that are considering or actively developing cardiac arrest centers of their own., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

This article summarizes the discussions of the emergency medical services (EMS) breakout session at the June 2010 Academic Emergency Medicine consensus conference "Beyond Regionalization: Integrated Networks of Emergency Care." The group focused on prehospital issues such as the identification of patients by EMS personnel, protocol-driven destination selection, bypassing closer nondesignated centers to transport patients directly to more distant designated specialty centers, and the modes of transport to be used as they relate to the regionalization of emergency care. It is our hope that the proposed research agenda will be advanced in a way that begins to rigorously approach the unanswered research questions and that these answers, in turn, will lead to an evidence-based, cohesive, comprehensive, and more uniform set of guidelines that govern the delivery and practice of prehospital emergency care., (2010 by the Society for Academic Emergency Medicine.)

Study Objective: The Institute of Medicine Committee on the Future of Emergency Care in the United States Health System (2003) identified a need to enhance the research base for emergency care. As a result, a National Institutes of Health (NIH) Task Force on Research in Emergency Medicine was formed to enhance NIH support for emergency care research. Members of the NIH Task Force and academic leaders in emergency care participated in 3 Roundtable discussions to prioritize current opportunities for enhancing and conducting emergency care research. We identify key research questions essential to advancing the science of emergency care and discuss the barriers and strategies to advance research by exploring the collaboration between NIH and the emergency care community., Methods: Experts from emergency medicine, neurology, psychiatry, and public health assembled to review critical areas in need of investigation, current gaps in knowledge, barriers, and opportunities. Neurologic emergencies included cerebral resuscitation, pain, stroke, syncope, traumatic brain injury, and pregnancy. Mental health topics included suicide, agitation and delirium, substances, posttraumatic stress, violence, and bereavement., Results: Presentations and group discussion firmly established the need for translational research to bring basic science concepts into the clinical arena. A coordinated continuum of the health care system that ensures rapid identification and stabilization and extends through discharge is necessary to maximize overall patient outcomes. There is a paucity of well-designed, focused research on diagnostic testing, clinical decisionmaking, and treatments in the emergency setting. Barriers include the limited number of experienced researchers in emergency medicine, limited dedicated research funding, and difficulties of conducting research in chaotic emergency environments stressed by crowding and limited resources. Several themes emerged during the course of the roundtable discussion, including the need for development of (1) a research infrastructure for the rapid identification, consent, and tracking of research subjects that incorporates innovative informatics technologies, essential for future research; (2) diagnostic strategies and tools necessary to understand key populations and the process of medical decisionmaking, including the investigation of the pathobiology of symptoms and symptom-oriented therapies; (3) collaborative research networks to provide unique opportunities to form partnerships, leverage patient cohorts and clinical and financial resources, and share data; (4) formal research training programs integral for creating new knowledge and advancing the science and practice of emergency medicine; and (5) recognition that emergency care is part of an integrated system from emergency medical services dispatch to discharge. The NIH Roundtable "Opportunities to Advance Research on Neurological and Psychiatric Emergencies" created a framework to guide future emergency medicine-based research initiatives., Conclusion: Emergency departments provide the portal of access to the health care system for most patients with acute neurologic and psychiatric illness. Emergency physicians and colleagues are primed to investigate neurologic and psychiatric emergencies that will directly improve the delivery of care and patient outcomes., (Copyright © 2010. Published by Mosby, Inc.)

Objective. To analyze the effect of basic resuscitation efforts on gasping and of gasping on survival. Methods. This is secondary analysis of a previously reported study comparing continuous chest compressions (CCC CPR) versus chest compressions plus ventilation (30:2 CPR) on survival. 64 swine were randomized to 1 of these 2 basic CPR approaches after either short (3 or 4 minutes) or long (5 or 6 minutes) durations of untreated VF. At 12 minutes of VF, all received the same Guidelines 2005 Advanced Cardiac Life Support. Neurologically status was evaluated at 24 hours. A score of 1 is normal, 2 is abnormal, such as not eating or drinking normally, unsteady gait, or slight resistance to restraint, 3 severely abnormal, where the animal is recumbent and unable to stand, 4 is comatose, and 5 is dead. For this analysis a neurological outcome score of 1 or 2 was classified as "good", and a score of 3, 4, or 5 was classified as "poor." Results. Gasping was more likely to continue or if absent, to resume in the animals with short durations of untreated VF before basic resuscitation efforts. With long durations of untreated VF, the frequency of gasping and survival was better in swine receiving CCC CPR. In the absence of frequent gasping, intact survival was rare in the long duration of untreated VF group. Conclusions. Gasping is an important phenomenon during basic resuscitation efforts for VF arrest and in this model was more frequent with CCC-CPR.

Study Objective: Assisted ventilation may adversely affect out-of-hospital cardiac arrest outcomes. Passive ventilation offers an alternate method of oxygen delivery for these patients. We compare the adjusted neurologically intact survival of out-of-hospital cardiac arrest patients receiving initial passive ventilation with those receiving initial bag-valve-mask ventilation., Methods: The authors performed a retrospective analysis of statewide out-of-hospital cardiac arrests between January 1, 2005, and September 28, 2008. The analysis included consecutive adult out-of-hospital cardiac arrest patients receiving resuscitation with minimally interrupted cardiopulmonary resuscitation (CPR) consisting of uninterrupted preshock and postshock chest compressions, initial noninvasive airway maneuvers, and early epinephrine. Paramedics selected the method of initial noninvasive ventilation, consisting of either passive ventilation (oropharyngeal airway insertion and high-flow oxygen by nonrebreather facemask, without assisted ventilation) or bag-valve-mask ventilation (by paramedics at 8 breaths/min). The authors determined adjusted neurologically intact survival from hospital and public records and by telephone interview and mail questionnaire. The authors compared adjusted neurologically intact survival between ventilation techniques by using generalized estimating equations., Results: Among the 1,019 adult out-of-hospital cardiac arrest patients in the analysis, 459 received passive ventilation and 560 received bag-valve-mask ventilation. Adjusted neurologically intact survival after witnessed ventricular fibrillation/ventricular tachycardia out-of-hospital cardiac arrest was higher for passive ventilation (39/102; 38.2%) than bag-valve-mask ventilation (31/120; 25.8%) (adjusted odds ratio [OR] 2.5; 95% confidence interval [CI] 1.3 to 4.6). Survival between passive ventilation and bag-valve-mask ventilation was similar after unwitnessed ventricular fibrillation/ventricular tachycardia (7.3% versus 13.8%; adjusted OR 0.5; 95% CI 0.2 to 1.6) and nonshockable rhythms (1.3% versus 3.7%; adjusted OR 0.3; 95% CI 0.1 to 1.0)., Conclusion: Among adult, witnessed, ventricular fibrillation/ventricular tachycardia, out-of-hospital cardiac arrest resuscitated with minimally interrupted cardiac resuscitation, adjusted neurologically intact survival to hospital discharge was higher for individuals receiving initial passive ventilation than those receiving initial bag-valve-mask ventilation.

A rural-urban disparity exists in acute stroke management practices in Arizona. A proposed solution is a statewide acute stroke care plan centered on stroke telemedicine. Our purpose was to evaluate the emergency stroke resources available at and care provided by remote Arizona hospitals and to formulate a 5-year stroke telemedicine plan for Arizona rural residents. We used the Arizona Hospital and Healthcare Association Web site to identify all eligible institutions. Consenting personnel were mailed the survey on behalf of the Arizona Department of Health Services. To construct the 5-year telemedicine plan, we used survey data as well as our previously designed stroke telemedicine research trial. We estimated the resources, the geographic coverage, and the operating costs. Thirty-five hospitals met survey eligibility criteria; however, 24/35 (69%) hospitals completed the survey. Only one hospital had neurologists on call 24/7. Hospitals thrombolysed 2%-4% of all stroke patients annually. Ninety percent of the hospitals were interested in participating in a statewide telemedicine initiative. The stroke telemedicine plan divided Arizona into two regions, each with a one-hub to three-spoke ratio. The budget was estimated to be U.S. $8,141,217.10 for 5 years. Remote communities of Arizona were underserviced with regard to the availability of neurologists and the delivery of emergency stroke care. The majority of the remote emergency departments were interested in participating as spoke sites in a statewide stroke telemedicine initiative. Telemedicine may be an effective method to provide expert care to stroke patients located in rural areas.

Study Objective: To identify any association between out-of-hospital transport interval and survival to hospital discharge in victims of out-of-hospital cardiac arrest., Methods: Data from the Ontario Prehospital Advanced Life Support Study (January 1, 1991, to December 31, 2002), an Utstein-compliant registry of out-of-hospital cardiac arrest patients from 21 communities, were analyzed. Logistic regression identified factors that were independently associated with survival in consecutive adult, nontraumatic, out-of-hospital cardiac arrest patients and in the subgroup with return of spontaneous circulation., Results: A total of 18,987 patients met criteria and 15,559 (81.9%) had complete data for analysis (study group). Return of spontaneous circulation was achieved in 2,299 patients (14.8%), and 689 (4.4%) survived to hospital discharge. Median transport interval was 4.0 minutes (25th quartile 3.0 minutes; 75th quartile 6.2 minutes) for survivors and 4.2 minutes (25th quartile 3.0, 75th quartile 6.2) for nonsurvivors. Logistic regression revealed multiple factors that were independently associated with survival: witnessed arrest (odds ratio 2.61; 95% confidence interval [CI] 2.05 to 3.34), bystander cardiopulmonary resuscitation (odds ratio 2.22; 95% CI 1.82 to 2.70), initial rhythm of ventricular fibrillation/tachycardia (odds ratio 2.22; 95% CI 1.97 to 2.50), and shorter emergency medical services (EMS) response interval (odds ratio 1.26; 95% CI 1.20 to 1.33). There was no association between transport interval and survival in either the study group (odds ratio 1.01; 95% CI 0.99 to 1.05) or the return of spontaneous circulation subgroup (odds ratio 1.04; 95% CI 0.99, 1.08)., Conclusion: In a large out-of-hospital cardiac arrest study from demographically diverse EMS systems, longer transport interval was not associated with decreased survival. Given the growing evidence showing major influence from specialized postarrest care, these findings support conducting clinical trials that assess the effectiveness and safety of bypassing local hospitals to take patients to regional cardiac arrest centers.

Background: The rate of patients being treated with thrombolytic therapy is low, in part, due to a shortage of vascular neurologists, especially in rural communities. Two-way audio-video communication through telemedicine has been demonstrated to be a reliable method to assess neurologic deficits due to stroke and maybe more efficacious in determining thrombolytic therapy eligibility than telephone-only consultation., Objective: To determine the efficacy of telemedicine versus telephone-only consultations for decision making in acute stroke situations., Methods: The objective was addressed through the development of a structured, critically appraised topic. Participants included consultant and resident neurologists, clinical epidemiologists, medical librarian, and clinical content experts in the fields of vascular neurology, emergency medicine, and telemedicine. Participants started with a clinical scenario and a structured question, devised search strategies, located and compiled the best evidence, performed a critical appraisal, synthesized the results, summarized the evidence, provided commentary, and declared bottom-line conclusions., Results: : A single randomized, blinded, prospective trial comparing telephone-only consultations to telemedicine consultations for acute stroke was selected and appraised. Correct acute stroke treatment decisions were made more often in the telemedicine group versus the telephone-only group (98% vs. 82%, [number needed to assess = 6]). Stroke telemedicine when compared with telephone-only consultations was more sensitive (100% vs. 58%), more specific (98% vs. 92%), had a more favorable positive likelihood ratio (LR: 41 vs. 7) and negative likelihood ratio (LR: 0 vs. 0.5), and had higher predictive values (positive predictive value 94% vs. 76%, and negative predictive value 100% vs. 84%) for the determination of thrombolysis eligibility., Conclusion: Stroke telemedicine when compared with telephone-only consultations is an effective method to determine thrombolysis eligibility for acute stroke patients who do not have immediate access to a stroke neurologist.

Background: Despite a large body of resuscitation research, the optimal timing and approach to prognosticating futility after nontraumatic cardiac arrest remains controversial. Postresuscitation anoxic-ischemic encephalopathy may leave patients cognitively disabled and dependent, minimally conscious, or in a persistent vegetative state. Neurologists are frequently called upon to assess comatose postcardiac arrest patients to communicate accurate prognostic information and to assist in planning the most appropriate level of care. Serum neuron specific enolase (NSE), when used in conjunction with other available prognostic tools, may be a useful tool for predicting clinical outcome in this patient population., Objective: Determine the clinical utility of a serum NSE measurement for predicting the neurologic outcome of a survivor after resuscitation from a nontraumatic cardiac arrest., Methods: We addressed the question through the development of a structured, critically appraised topic. Participants included consultant and resident neurologists, clinical epidemiologists, medical librarian, and clinical content experts in the fields of emergency medicine, cardiac resuscitation, and critical care neurology. Participants started with a clinical scenario and a structured question, devised search strategies, located and compiled the best evidence, performed a critical appraisal, synthesized the results, summarized the evidence, provided commentary, and declared bottom-line conclusions., Results: A single recent prospective cohort study, which assessed the predictive value of serum NSE was selected and appraised. A level of 80 ng/mL was determined to predict persistent coma with a sensitivity of 63% (95% CI, 49%-75%), and a specificity of 100% (95% CI, 97%-100%), positive predictive value (PPV) of 100%, negative predictive value (NPV) of 84%, and a negative LR of 0.37., Conclusions: The specificity of serum NSE levels >80 ng/mL is sufficiently high that, when it is used with other clinical and electrophysiological data, it could be useful as a prognostic indicator of neurologic outcome after cardiac arrest. Although serum NSE is an appealing, simple, readily available test, prediction of neurologic outcome after resuscitation from cardiac arrest must not rely solely on a serum biomarker, but must be determined in the context of other patient characteristics and neurologic examination findings.

Objective: There is growing evidence that therapeutic hypothermia and other post-resuscitation care improves outcomes in out-of-hospital cardiac arrest (OHCA). Thus, transporting patients with return of spontaneous circulation (ROSC) to specialized facilities may increase survival rates. However, it is unknown whether prolonging transport to reach a designated facility would be detrimental., Methods: Data from OHCA patients treated in EMS systems that cover approximately 70% of Arizona's population were evaluated (October 2004-December 2006). We analyzed the association between transport interval (depart scene to ED arrival) and survival to hospital discharge in adult, non-traumatic OHCA patients and in the subgroup who achieved ROSC and remained comatose., Results: 1846 OHCA occurred prior to EMS arrival. Complete transport interval data were available for 1177 (63.8%) patients (study group). 253 patients (21.5%) achieved ROSC and remained comatose making them theoretically eligible for transport to specialized care. Overall, 70 patients (5.9%) survived and 43 (17.0%) comatose ROSC patients survived. Mean transport interval for the study group was 6.9 min (95% CI: 6.7, 7.1). Logistic regression revealed factors that were independently associated with survival: witnessed arrest, bystander CPR, method of CPR, initial rhythm of ventricular fibrillation, and shorter EMS response time interval. There was no significant association between transport interval and outcome in either the overall study group (OR=1.2; 0.77, 1.8) or in the comatose, ROSC subgroup (OR 0.94; 0.51, 1.8)., Conclusion: Survival was not significantly impacted by transport interval. This suggests that a modest increase in transport interval from bypassing the closest hospital en route to specialized care is safe and warrants further investigation.

Background: Only a few large cities have published their out-of-hospital cardiac arrest (OHCA) survival statistics using the Utstein style reporting method. To date, to the best of our knowledge there has been no published OHCA survival data for a state., Objective: To describe the process, benefits, and challenges of establishing a statewide OHCA database and educational network., Methods: Arizona's Bureau of Emergency Medical Services and Trauma System initiated a statewide, prospective, observational cohort review of all OHCA victims on whom resuscitation was attempted in the field. Emergency medical services (EMS) first care reports, voluntarily submitted by 35 departments in Arizona, were analyzed. We chronicled the development of our data-collection process along with how we obtained patient outcomes and delivered feedback to field providers. Entry data included time intervals and nodal events conforming to the Utstein style template., Results: In data collected between January 1, 2005, and April 1, 2006, there were 1,484 OHCAs reported, of which 1,104 were of presumed cardiac etiology occurring prior to EMS arrival. The OHCA incidence was approximately 0.44 per 1,000 population per year. In our database, bystander CPR provided an odds ratio of 3.0 for survival (95% confidence interval 1.3, 6.7). Outcomes for 1,076 patients were obtained. Thirty-seven (3.4%) of the 1,076 cardiac arrest victims survived to hospital discharge. Twenty-seven (8.6%) of the 331 ventricular fibrillation cardiac arrest victims survived to hospital discharge., Conclusion: It is feasible for a public health agency to implement a voluntary, statewide data-collection system and educational network to determine and improve survival from OHCA.

Study Objective: The aim of this study is to compare rates of bystander cardiopulmonary resuscitation (CPR) for Hispanic and non-Hispanic out-of-hospital cardiac arrest (OOHCA) victims in Arizona., Methods: This is a secondary analysis of consecutive OOHCA victims prospectively enrolled into our statewide OOHCA quality improvement database between November 2004 and November 2006. Continuous data are presented as means +/- SDs and analyzed using t tests; categorical data are presented as frequency of occurrence and analyzed using chi(2). The primary outcome was whether bystander CPR rates were different for Hispanic vs non-Hispanic OOHCA victims. Secondary comparisons were initial cardiac rhythms and survival to hospital discharge., Results: There were 2411 OOHCA victims during the period of analysis. A total of 952 arrests were excluded because ethnicity was not documented; 80 arrests were excluded because they were traumatic. A total of 1379 arrests were included for analysis, of which 273 (19.8%) were Hispanic. Hispanics were less likely to receive bystander CPR than non-Hispanics (32.2% vs 41.5%; P < .0001). Hispanics and non-Hispanics were dissimilar with respect to age (53.2 +/- 25 vs 64.5 +/- 19.3 years; P = .0001), paramedic response time (5.1 vs 5.5 minutes; P = .0006), initial rhythm asystole (53.8% vs 44.5%; P = .005), and initial rhythm ventricular fibrillation (20.5% vs 26.7%; P = .036). Survival to hospital discharge (8.1% vs 7.1%) was not statistically different., Conclusion: In the state of Arizona, significantly fewer Hispanic OOHCA victims receive bystander CPR than non-Hispanics.

Objectives: Recently, investigators described a clinical decision rule for termination of resuscitation (TOR) designed to help determine whether to terminate emergency medical services (EMS) resuscitative efforts for out-of-hospital cardiac arrests (OOHCA). The authors sought to evaluate the hypothesis that TOR would predict no survival for patients in an independent cohort of patients with OOHCA., Methods: This was a retrospective cohort analysis conducted in the state of Arizona. Consecutive, adult, OOHCA were prospectively evaluated from October 2004 through October 2006. A statewide OOHCA database utilizing Utstein-style reporting from 30 different EMS systems was used. Data were abstracted from EMS first care reports and hospital discharge records. The TOR guidelines predict that no survival to hospital discharge will occur if 1) an OOHCA victim does not have return of spontaneous circulation (ROSC), 2) no shocks are administered, and 3) the arrest is not witnessed by EMS personnel. Data were entered into a structured database. Continuous data are presented as means (+/-standard deviations [SD]) and categorical data as frequency of occurrence, and 95% confidence intervals (CIs) were calculated as appropriate. The primary outcome measure was to determine if any cohort member who met TOR criteria survived to hospital discharge., Results: There were 2,239 eligible patients; the study group included 2,180 (97.4%) patients for whom the data were complete; mean age was 64 (+/-11) years, and 35% were female. The majority of patients in the study group met at least one or more of the TOR criteria. A total of 2,047 (93.8%) patients suffered from cardiac arrest that was unwitnessed by EMS; 1,653 (75.8%) had an unwitnessed arrest and no ROSC. With respect to TOR, 1,160 of 2,180 (53.2%) patients met all three criteria; only one (0.09%; 95% CI = 0% to 0.5%) survived to hospital discharge., Conclusions: The authors evaluated TOR guidelines in an independent, statewide OOHCA database. The results are consistent with the findings of the TOR investigation and suggest that this algorithm is a promising tool for TOR decision-making in the field.

Context: Out-of-hospital cardiac arrest is a major public health problem., Objective: To investigate whether the survival of patients with out-of-hospital cardiac arrest would improve with minimally interrupted cardiac resuscitation (MICR), an alternate emergency medical services (EMS) protocol., Design, Setting, and Patients: A prospective study of survival-to-hospital discharge between January 1, 2005, and November 22, 2007. Patients with out-of-hospital cardiac arrests in 2 metropolitan cities in Arizona before and after MICR training of fire department emergency medical personnel were assessed. In a second analysis of protocol compliance, patients from the 2 metropolitan cities and 60 additional fire departments in Arizona who actually received MICR were compared with patients who did not receive MICR but received standard advanced life support., Intervention: Instruction for EMS personnel in MICR, an approach that includes an initial series of 200 uninterrupted chest compressions, rhythm analysis with a single shock, 200 immediate postshock chest compressions before pulse check or rhythm reanalysis, early administration of epinephrine, and delayed endotracheal intubation., Main Outcome Measure: Survival-to-hospital discharge., Results: Among the 886 patients in the 2 metropolitan cities, survival-to-hospital discharge increased from 1.8% (4/218) before MICR training to 5.4% (36/668) after MICR training (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.1-8.9). In the subgroup of 174 patients with witnessed cardiac arrest and ventricular fibrillation, survival increased from 4.7% (2/43) before MICR training to 17.6% (23/131) after MICR training (OR, 8.6; 95% CI, 1.8-42.0). In the analysis of MICR protocol compliance involving 2460 patients with cardiac arrest, survival was significantly better among patients who received MICR than those who did not (9.1% [60/661] vs 3.8% [69/1799]; OR, 2.7; 95% CI, 1.9-4.1), as well as patients with witnessed ventricular fibrillation (28.4% [40/141] vs 11.9% [46/387]; OR, 3.4; 95% CI, 2.0-5.8)., Conclusions: Survival-to-hospital discharge of patients with out-of-hospital cardiac arrest increased after implementation of MICR as an alternate EMS protocol. These results need to be confirmed in a randomized trial.

The objective of this study was to assess the ability of citizens in a senior living community (SLC) to perform adequate cardiopulmonary resuscitation (CPR) and appropriately utilize an automated external defibrillator (AED) in a simulated cardiac arrest scenario (SCAS). This study was a prospective, observational study; a convenience sample of SLC residents aged > 54 years was enrolled. Subjects were presented with a SCAS (adult mannequin, bystander available to assist, AED visible). Subjects' skills were rated in standardized fashion. For statistical analysis, 95% confidence intervals (CIs) were calculated as appropriate. There were 51 subjects; 69% were female; mean age was 64 years; 86% were without disabilities. Pre-retirement professions included: medical (13.7%), office/sales (41.2%), and engineer/science (15.7%). Subjects had previous American Heart Association first-responder training (CPR and AED use) as follows: none (22%), within 0 to 6 months (47%), 7-12 months (4%), > 12 months (27%). During the SCAS, subjects performed inconsistently on the various links in the chain of survival. Although most subjects (94%; 95% CI 84-99%) checked for unresponsiveness, only 62.8% (95% CI 48-76%) also specified "call 911 and bring me the AED." Most subjects (88%; 95% CI 76-96%) started chest compressions, however, only a minority provided high quality chest compressions (29%; 95% CI 17-44%). With respect to AED skill performance, we noted the following: 94% (95% CI 84-99%) of subjects removed the patient's clothing, 90% (95% CI 79-97%) turned the device on, 94% delivered a shock as directed, and 82% continued CPR if "no shock indicated" by AED (95% CI 69-92%). Performance was less satisfactory for the following: only 39.2% (95% CI 26-54%) continued chest compressions after AED arrival, 60.8% (95% CI 46-74%) of subjects correctly attached electrodes, and 6% (95% CI 1-16%) verbalized "clear" in advance of shock. Although many members of our sample SLC had prior training, they frequently failed to adequately perform some key steps in the SCAS. Recent efforts to place AEDs in SLCs should be augmented by a plan to adequately train residents and other available individuals (e.g., staff) in CPR/AED use.

Background: Bystander cardiopulmonary resuscitation (CPR) decreases mortality from out-of-hospital cardiac arrest significantly. Accordingly, layperson CPR is an integral component in the chain of survival for out-of-hospital cardiac arrest victims. The near statewide incidence and location of layperson CPR is unknown., Objective: To determine true incidence and location of layperson CPR in the State of Arizona., Methods: The Save Hearts in Arizona Registry and Education (SHARE) program reviewed EMS first care reports submitted voluntarily by 30 municipal fire departments responsible for approximately 67% of Arizona's population. In addition to standard Utstein style data, information regarding the performance of bystander CPR, the vocation and medical training of the bystander and the location of the arrest were documented., Results: The total number of out-of-hospital adult arrests of presumed cardiac etiology reported statewide was 1097. Cardiac arrests occurred in private residences in 67%, extended care or medical facilities in 18%, and public locations in 15%. Bystander CPR was performed in 37% of all arrests, 24% of residential arrests, 76% of extended care or medical facility arrests, and 52% of public arrests. Bystander CPR provided an odds ratio of 2.2 for survival [95% CI 1.2-4.1]. Excluding cardiac arrests which occurred in the presence of bystanders with formal CPR training as part of their job description, layperson CPR was performed in 218 of 857 (25%) of cases., Conclusions: The near statewide incidence of layperson CPR is extremely low. This low rate of bystander CPR is likely to contribute to the low overall survival rates from cardiac arrest. Public health officials should re-evaluate current models of public education on CPR.

Introduction: The Privacy Rule, a follow-up to the Health Insurance Portability and Accountability Act, limits distribution of protected health information. Compliance with the Privacy Rule is particularly challenging for prehospital research, because investigators often seek data from multiple emergency medical services (EMS) and receiving hospitals., Objective: To describe the impact of the Privacy Rule on prehospital research and to present strategies to optimize data collection in compliance with the Privacy Rule. Methods. The CanAm Pediatric Cardiopulmonary Arrest Study Group has previously conducted a multicentered observational study involving children with out-of-hospital cardiac arrest. In the current study, we used a survey to assess site-specific methods of compliance with the Privacy Rule and the extent to which such strategies were successful., Results: The previously conducted observational study included collection of data from a total of 66 EMS agencies (range of 1-37 per site). Data collection from EMS providers was complicated by the lack of a systematic approval mechanism for the research use of EMS records and by incomplete resuscitation records. Agencies approached for approval to release EMS data for study purposes included Department of Health Institutional Review Boards, Fire Commissioners, and Commissioners of Health. The observational study included collection of data from a total of 164 receiving hospitals (range of 1-63 per site). Data collection from receiving hospitals was complicated by the varying requirements of receiving hospitals for the release of patient survival data., Conclusions: Obtaining complete EMS and hospital data is challenging but is vital to the conduct of prehospital research. Obtaining approval from city or state level IRBs or Privacy Boards may help optimize data collection. Uniformity of methods to adhere to regulatory requirements would ease the conduct of prehospital research.

Objective: To evaluate a new, 1-h, condensed training programme to teach continuous chest compression cardiopulmonary resuscitation (CCC-CPR) and automated external defibrillator (AED) skills to a cohort of eight grade public school students., Results: Thirty-three eligible subjects completed the programme; mean age 13.7 years; 48.5% female. Eight participants reported some prior training in CPR and AED use. Following initial training, 29/33 (87.8%) subjects demonstrated proficiency at CCC-CPR and AED application/operation in a mock adult cardiac arrest scenario. At four-weeks, 28/33 (84.8%) subjects demonstrated skill retention in similar scenario testing. Subjects also showed improvement in written knowledge regarding AED use as shown by scores on an AHA based written exam (60.9% versus 77.3%; p<0.001)., Conclusion: With our focused, condensed training program, eighth grade public school students became proficient in CCC-CPR and AED use. This is the first study to document the ability of middle school students to learn and retain CCC-CPR and AED skills for adult sudden cardiac arrest victims with such a curriculum.

Study Objective: To determine the prevalence of bacteremia associated with incision and drainage (I&D) of cutaneous abscesses in afebrile adult emergency department patients. Such information has implications for the ED management of immunocompromised patients, patients with history of endocarditis, and patients with prosthetic appliances such as heart valves and artificial joints., Methods: We conducted a prospective clinical study in the adult ED of an urban tertiary care teaching hospital. Our subjects were afebrile patients aged 18 to 65 years with localized, nondraining, purulent cutaneous abscesses requiring outpatient surgical management. Before I&D, blood for aerobic and anaerobic blood culture was drawn under sterile conditions. The wound was opened and samples for aerobic wound culture were obtained. Two and 10 minutes after I&D, blood was again drawn, from separate venipunctures. All patients were discharged home with ED follow-up scheduled 48 hours later., Results: From the 50 patients who completed the study, 150 blood samples (50 before and 100 after I&D) and 50 wound samples were obtained. No blood culture was positive, but 30 wound cultures (64%) were positive; the most commonly isolated organism was Staphylococcus aureus., Conclusion: I&D of localized cutaneous abscesses in afebrile adults is unlikely to result in transient bacteremia. Larger studies are needed to determine whether routine antibiotic prophylaxis is necessary for afebrile patients undergoing I&D.

A case of necrotizing fasciitis complicating missed appendicitis with perforation and abscess formation in a 63-year-old diabetic is presented. The case emphasizes the importance of thorough, conservative evaluation and management in elderly diabetic patients. The ED management of patients with necrotizing fasciitis is also briefly reviewed.