CPR in medical schools: learning by teaching BLS to sudden cardiac death survivors – a promising strategy for medical students?

BACKGROUND: Cardiopulmonary resuscitation (CPR) training is gaining more importance for medical students. There were many attempts to improve the basic life support (BLS) skills in medical students, some being rather successful, some less. We developed a new problem based learning curriculum, where students had to teach CPR to cardiac arrest survivors in order to improve the knowledge about life support skills of trainers and trainees. METHODS: Medical students who enrolled in our curriculum had to pass a 2 semester problem based learning session about the principles of cardiac arrest, CPR, BLS and defibrillation (CPR-D). Then the students taught cardiac arrest survivors who were randomly chosen out of a cardiac arrest database of our emergency department. Both, the student and the Sudden Cardiac Death (SCD) survivor were asked about their skills and knowledge via questionnaires immediately after the course. The questionnaires were then used to evaluate if this new teaching strategy is useful for learning CPR via a problem-based-learning course. The survey was grouped into three categories, namely "Use of AED", "CPR-D" and "Training". In addition, there was space for free answers where the participants could state their opinion in their own words, which provided some useful hints for upcoming programs. RESULTS: This new learning-by-teaching strategy was highly accepted by all participants, the students and the SCD survivors. Most SCD survivors would use their skills in case one of their relatives goes into cardiac arrest (96%). Furthermore, 86% of the trainees were able to deal with failures and/or disturbances by themselves. On the trainer's side, 96% of the students felt to be well prepared for the course and were considered to be competent by 96% of their trainees. CONCLUSION: We could prove that learning by teaching CPR is possible and is highly accepted by the students. By offering a compelling appreciation of what CPR can achieve in using survivors from SCD as trainees made them go deeper into the subject of resuscitation, what also might result in a longer lasting benefit than regular lecture courses in CPR

Brain Stem Death as the Vital Determinant for Resumption of Spontaneous Circulation after Cardiac Arrest in Rats

BACKGROUND:Spontaneous circulation returns to less than half of adult cardiac arrest victims who received in-hospital resuscitation. One clue for this disheartening outcome arises from the prognosis that asystole invariably takes place, after a time lag, on diagnosis of brain stem death. The designation of brain stem death as the point of no return further suggests that permanent impairment of the brain stem cardiovascular regulatory machinery precedes death. It follows that a crucial determinant for successful revival of an arrested heart is that spontaneous circulation must resume before brain stem death commences. Here, we evaluated the hypothesis that maintained functional integrity of the rostral ventrolateral medulla (RVLM), a neural substrate that is intimately related to brain stem death and central circulatory regulation, holds the key to the vital time-window between cardiac arrest and resumption of spontaneous circulation. METHODOLOGY/PRINCIPAL FINDINGS:An animal model of brain stem death employing the pesticide mevinphos as the experimental insult in Sprague-Dawley rats was used. Intravenous administration of lethal doses of mevinphos elicited an abrupt cardiac arrest, accompanied by elevated systemic arterial pressure and anoxia, augmented neuronal excitability and enhanced microvascular perfusion in RVLM. This period represents the vital time-window between cardiac arrest and resumption of spontaneous circulation in our experimental model. Animals with restored spontaneous circulation exhibited maintained neuronal functionality in RVLM beyond this critical time-window, alongside resumption of baseline tissue oxygen and enhancement of local blood flow. Intriguingly, animals that subsequently died manifested sustained anoxia, diminished local blood flow, depressed mitochondrial electron transport activities and reduced ATP production, leading to necrotic cell death in RVLM. That amelioration of mitochondrial dysfunction and bioenergetic failure in RVLM by coenzyme Q10, the mobile electron carrier in mitochondrial respiratory chain, or oxygenation restored spontaneous circulation further established a causal relationship between functionality of RVLM and resumed spontaneous circulation after cardiac arrest. CONCLUSIONS/SIGNIFICANCE:We conclude that whereas necrotic cell death because of bioenergetic failure triggered by anoxia in RVLM, which precipitates brain stem death, negates resuscitation of an arrested heart, maintained functional integrity of this neural substrate holds the key to resumption of spontaneous circulation after cardiac arrest in rats

Hands-on time during cardiopulmonary resuscitation is affected by the process of teambuilding: a prospective randomised simulator-based trial

BACKGROUND: Cardiac arrests are handled by teams rather than by individual health-care workers. Recent investigations demonstrate that adherence to CPR guidelines can be less than optimal, that deviations from treatment algorithms are associated with lower survival rates, and that deficits in performance are associated with shortcomings in the process of team-building. The aim of this study was to explore and quantify the effects of ad-hoc team-building on the adherence to the algorithms of CPR among two types of physicians that play an important role as first responders during CPR: general practitioners and hospital physicians. METHODS: To unmask team-building this prospective randomised study compared the performance of preformed teams, i.e. teams that had undergone their process of team-building prior to the onset of a cardiac arrest, with that of teams that had to form ad-hoc during the cardiac arrest. 50 teams consisting of three general practitioners each and 50 teams consisting of three hospital physicians each, were randomised to two different versions of a simulated witnessed cardiac arrest: the arrest occurred either in the presence of only one physician while the remaining two physicians were summoned to help ("ad-hoc"), or it occurred in the presence of all three physicians ("preformed"). All scenarios were videotaped and performance was analysed post-hoc by two independent observers. RESULTS: Compared to preformed teams, ad-hoc forming teams had less hands-on time during the first 180 seconds of the arrest (93 +/- 37 vs. 124 +/- 33 sec, P > 0.0001), delayed their first defibrillation (67 +/- 42 vs. 107 +/- 46 sec, P > 0.0001), and made less leadership statements (15 +/- 5 vs. 21 +/- 6, P > 0.0001). CONCLUSION: Hands-on time and time to defibrillation, two performance markers of CPR with a proven relevance for medical outcome, are negatively affected by shortcomings in the process of ad-hoc team-building and particularly deficits in leadership. Team-building has thus to be regarded as an additional task imposed on teams forming ad-hoc during CPR. All physicians should be aware that early structuring of the own team is a prerequisite for timely and effective execution of CPR

After-hours colorectal surgery: a risk factor for anastomotic leakage

__Purpose:__ This study aims to increase knowledge of colorectal anastomotic leakage by performing an incidence study and risk factor analysis with new potential risk factors in a Dutch tertiary referral center. __Methods:__ All patients whom received a primary colorectal anastomosis between 1997 and 2007 were selected by means of operation codes. Patient records were studied for population description and risk factor analysis. __Results:__ In total 739 patients were included. Anastomotic leakage (AL) occurred in 64 (8.7%) patients of whom nine (14.1%) died. Median interval between operation and diagnosis was 8 days. The risk for AL was higher as the anastomoses were constructed more distally (p = 0.019). Univariate analysis showed duration of surgery (p = 0.038), BMI (p = 0.001), time of surgery (p = 0.029), prophylactic drainage (p = 0.006) and time under anesthesia (p = 0.012) to be associated to AL. Multivariate analysis showed BMI greater than 30 kg/m2(p = 0.006; OR 2.6 CI 1.3-5.2) and "after hours" construction of an anastomosis (p = 0.030; OR 2.2 CI 1.1-4.5) to be independent risk factors. __Conclusion:__ BMI greater than 30 kg/m2and "after hours" construction of an anastomosis were independent risk factors for colorectal anastomotic leakage