Practice characteristics of Emergency Department extracorporeal cardiopulmonary resuscitation (eCPR) programs in the United States: The current state of the art of Emergency Department extracorporeal membrane oxygenation (ED ECMO).

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 (\u3e85%) 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

Medical emergencies in dental practice

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

High Serum Tumor Necrosis Factor Levels in the Early Post-Cardiac Arrest Period Are Associated with Poor Short-Term Survival in a Swine Model of Ventricular Fibrillation

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

High Serum Tumor Necrosis Factor Levels in the Early Post-Cardiac Arrest Period Are Associated with Poor Short-Term Survival in a Swine Model of Ventricular Fibrillation

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

Edible Cricothyrotomy Model: A Low-Cost Alternative to Pig Tracheas and Plastic Models for Teaching Cricothyrotomy

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

Cardiac Function and the Proinflammatory Cytokine Response After Recovery From Cardiac Arrest in Swine

Increased levels of cytokines have been reported after resuscitation from cardiac arrest. We hypothesized that proinflammatory cytokines, released in response to ischemia/reperfusion, increase following resuscitation and play a role in post–cardiac arrest myocardial dysfunction. Ventricular fibrillation (VF) was induced by coronary occlusion in 20 swine. After 7 min of VF, resuscitation was performed as per guidelines. Plasma levels of tumor necrosis factor (TNF)-α, interleukin (IL)-1β, and IL-6 were measured 15 min after the start of resuscitation in all animals and at intervals of 6 h in resuscitated animals. Intravascular pressures and cardiac output (CO) were also recorded. TNF-α abruptly increased after resuscitation, peaking at 15 min following return of spontaneous circulation, and declined to baseline levels after 3 h. IL-1β increased more slowly, reaching a maximum 2 h after reperfusion. IL-6 concentrations were not significantly different from control values at any time point. Males demonstrated greater elevations of TNF-α and IL-1β than females. Stroke work was significantly depressed at all time points with a nadir at 15–30 min after reperfusion, corresponding to the peak TNF-α values. The anti-TNF-α antibody infliximab attenuated the decrease in myocardial function observed 30 min after reperfusion. TNF-α increases during recovery from cardiac arrest are associated with depression of left ventricle (LV) function. The effect of TNF-α can be attenuated by anti-TNF-α antibodies

Endothelin-1 Is Not Predictive of Ventricular Ectopy or Ventricular Fibrillation during Acute Myocardial Ischemia

Endothelin(ET)-1 (ET-1) increases after myocardial infarction and may have effects on myocardial function. ET-1 has also been shown to affect the action potential (AP) which may be arrhythmogenic and predispose to ventricular fibrillation (VF). The effects of ET-2 and ET-3 are uncertain. We hypothesized that the ETs increase during acute ischemia and that plasma levels are predictive of ischemically induced VF. Thirty-four domestic swine underwent balloon occlusion of the proximal LAD coronary artery. Occlusion was confirmed angiographically. Venous samples were collected from the right atrium at baseline and at 5 min intervals for 30 min or until VF induction. ET-1, ET-2, and ET-3 were measured using ELISA. Changes in plasma concentrations were assessed using repeated measures ANOVA with Dunnett's. A p < 0.05 was considered statistically significant. All animals had angiographic evidence of successful proximal LAD occlusion. ET-1 levels were significantly increased from a baseline at 20 min and remained elevated during 30 min of occlusion. ET-2 and ET-3 levels did not change from baseline values (figure, mean ± SE). VF occurred in 60% of animals. Peak ET-1 values were not significantly different between VF and non-VF animals (6.2 ± 2.2 vs. 4.8 ± 2.3 pg/mL). No single ET-1 value had a VF predictive value >50%. There is a significant increase in ET-1 level within 20 min of acute myocardial ischemia. Despite known effects of ET-1 on the AP, this increase did not correlate with the occurrence of VF