Publications by authors named "Tyler F Vadeboncoeur"

38 Publications

Older adults on involuntary hold status in the emergency department.

Am J Emerg Med 2021 Jul 17;45:242-247. Epub 2020 Aug 17.

Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, Florida, United States of America.

Background: As the United States' population ages, the health care system will experience overall change. This study aims to identify factors in the older adult that may contribute to involuntary hold status in the ED.

Methods: This study is a retrospective review conducted at a suburban acute-care hospital ED of adult patients evaluated while on involuntary hold from January 1, 2014, through November 30, 2015. Older adults (patients born on or before 06/31/1964) were compared to younger adults (born on or after 07/01/1964) according to demographic and clinical variables including medical comorbidity, ED length of stay, reason for involuntary hold, psychiatric disorder, suicide attempt, substance use disorder, serum alcohol level, urine drug testing, medical comorbidity, violence in the ED, 30-day ED readmission, and 30-day mortality.

Results: Of 251 patients, 90 (35.9%) were older adults. The most common reason for involuntary hold in both cohorts was suicidal ideation. Medical comorbidities were more prevalent in older adults [60 (66.7%) vs. 64 (39.8%), P ≤.0001]. Older adults were less likely to report current drug abuse [31 (34.4%) vs. 77 (47.8%), P = .04]. The most commonly misused substance in both groups was alcohol; however, despite similar rates, blood alcohol levels (BAC) and urine drug screen (UDS) were performed less often in older adults. Cohorts were not significantly different with respect to sex, race, violence in the ED, psychiatric diagnosis, and ED LOS.

Conclusions: Involuntary older adult patients present with medical comorbidities that impact mental health. In the ED, they are less likely report substance use, and drug screening may be underutilized. Medical needs make their care unique and may present challenges in transfer of care to inpatient psychiatric facilities.
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http://dx.doi.org/10.1016/j.ajem.2020.08.043DOI Listing
July 2021

Use of a simulation-based advanced resuscitation training curriculum: Impact on cardiopulmonary resuscitation quality and patient outcomes.

J Intensive Care Soc 2020 Feb 7;21(1):57-63. Epub 2019 May 7.

Department of Emergency Medicine, Mayo Clinic in Florida, Jacksonville, FL, USA.

Background: Despite a continued focus on improved cardiopulmonary resuscitation quality, survival remains low from in-hospital cardiac arrest. Advanced Resuscitation Training has been shown to improve survival to hospital discharge and survival with good neurological outcome following in-hospital cardiac arrest at its home institution. We sought to determine if Advanced Resuscitation Training implementation would improve patient outcomes and cardiopulmonary resuscitation quality at our institution.

Methods: This was a prospective, before-after study of adult in-hospital cardiac arrest victims who had cardiopulmonary resuscitation performed. During phase 1, standard institution cardiopulmonary resuscitation training was provided. During phase 2, providers received the same quantity of training, but with emphasis on Advanced Resuscitation Training principles. Primary outcomes were return of spontaneous circulation, survival to hospital discharge, and neurologically favorable survival. Secondary outcomes were cardiopulmonary resuscitation quality parameters.

Results: A total of 156 adult in-hospital cardiac arrests occurred during the study period. Rates of return of spontaneous circulation improved from 58.1 to 86.3% with an adjusted odds ratios of 5.31 (95% CI: 2.23-14.35, P < 0.001). Survival to discharge increased from 26.7 to 41.2%, adjusted odds ratios 2.17 (95% CI: 1.02-4.67, P < 0.05). Survival with a good neurological outcome increased from 24.8 to 35.3%, but was not statistically significant. Target chest compression rate increased from 30.4% of patients in P1 to 65.6% in P2, adjusted odds ratios 4.27 (95% CI: 1.72-11.12, P = 0.002), and target depth increased from 23.2% in P1 to 46.9% in P2, adjusted odds ratios 2.92 (95% CI: 1.16-7.54, P = 0.024).

Conclusions: After Advanced Resuscitation Training implementation, there were significant improvements in cardiopulmonary resuscitation quality and rates of return of spontaneous circulation and survival to discharge.
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http://dx.doi.org/10.1177/1751143719838209DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7137161PMC
February 2020

Are pre-existing psychiatric disorders the only reason for involuntary holds in the emergency department?

Int J Emerg Med 2020 Feb 3;13(1). Epub 2020 Feb 3.

Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA.

Objectives: To determine the role of previous psychiatric disorders including substance use disorders on emergency department (ED) patients on involuntary holds and compare presentations, treatment, and outcomes based on cause.

Methods: We conducted a retrospective study of patients ≥ 18 years old on involuntary holds in the ED of a tertiary care center from January 1, 2013, to November 30, 2015. Demographic and clinical information were collected. Those with and without prior psychiatric disorder including substance use disorder were compared.

Results: We identified 251 patients of which 129 (51.4%) had a psychiatric disorder, 23 (9.2%) had a substance use disorder, and 86 (34.3%) had both. Thirteen patients (5.2%) had no psychiatric disorder or substance use disorder and the majority 10 (76.9%) were on involuntary holds due to suicidal threats related to pain or another medical problem. Patients without a psychiatric or substance use disorder were older (55 years [17.8] vs 42 [19]; P = 0.01), more likely to be married (10 [76.9%] vs 64 [26.9%]; P < 0.001), and had more medical comorbidities (10 [76.9%] vs 114 [47.9%]; P = 0.049) compared with those without a psychiatric or substance use disorder.

Conclusion: Patients on involuntary holds most commonly have pre-existing psychiatric disorder including substance use disorder. Patients on involuntary holds without history of psychiatric disorder often have severe pain or other active medical conditions which may contribute to suicidal thoughts. Addressing these underlying medical issues may be crucial in preventing further psychiatric decompensation.
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http://dx.doi.org/10.1186/s12245-020-0265-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6998304PMC
February 2020

Factors Associated With Half- and Full-Marathon Race-Related Injuries: A 3-Year Review.

Clin J Sport Med 2019 Dec 18. Epub 2019 Dec 18.

Biostatistics Unit, Mayo Clinic, Jacksonville, Florida.

Objective: To better evaluate the relationships between training, demographics, and injury, this study sought to define race-related injury risk factors for half- and full-marathon runners.

Design: This 3-year, observational cross-sectional study included adults who participated in a half or full marathon. Prerace and 2-week postrace surveys collected data on demographics, training factors, and injuries.

Setting: This study took place during a nationally recognized marathon affiliated with a local hospital.

Participants: Runners were recruited during the Expo in the days before the race. Postrace surveys were returned by 1043 half marathoners and 624 full marathoners (response rate, 83%).

Interventions: This was an observational study; independent variables included demographic data and race year.

Main Outcome Measure: The primary outcome was race-related injury that occurred during the race or within 2 weeks after the race.

Results: Race-related injuries were reported by 24% of half marathoners and 30% of full marathoners. For half and full marathoners, respectively, significant factors for injuries were previous injury, lower peak weekly training mileage, and lower weekly mileage before race training. Factors significant for only half-marathon injuries were younger age, female sex, shorter distance of longest training run, and no formal training program. Factors significant for only full-marathon injuries were higher body mass index, fewer days running per week, and fewer years of running experience.

Conclusions: Previous running injuries, undertraining, and inexperience increased race-related injury risk; women had higher risk than men. Decreased risk of injury was associated with training loads of greater than 23 miles/week for half marathoners and 40 miles/week for full marathoners.
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http://dx.doi.org/10.1097/JSM.0000000000000775DOI Listing
December 2019

Patients Threatening Harm to Others Evaluated in the Emergency Department under the Florida Involuntary Hold Act (Baker Act).

South Med J 2019 09;112(9):463-468

From the Division of Hospital Internal Medicine, the Division of Psychiatry, and the Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida, and the Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota.

Objectives: This study describes the specific threats of harm to others that led to the use of the Baker Act, the Florida involuntary hold act for emergency department (ED) evaluations. The study also summarizes patient demographics, concomitant psychiatric diagnoses, and emergent medical problems.

Methods: This is a retrospective review of 251 patients evaluated while on involuntary hold from January 1, 2014 through November 30, 2015 at a suburban acute care hospital ED. The data that were collected included demographic information, length of stay, reason for the involuntary hold, psychiatric disorder, substance use, medical illness, and violence in the ED. The context of the homicidal threat also was collected.

Results: We found that 13 patients (5.2%) were homicidal. Three patients had homicidal ideations alone, whereas 10 made homicidal threats toward others. Of the 10 making homicidal threats, 7 named a specific person to harm. Ten of the 13 homicidal patients (76.9%) also were suicidal. Eleven patients (84.6%) had a psychiatric disorder: 9 patients (69.2%) had a depressive disorder and 8 patients (61.5%) had a substance use disorder. Eight patients had active medical problems that required intervention in the ED.

Conclusions: We found that three-fourths of patients expressing homicidal threats also were suicidal. The majority of patients making threats of harm had a specific plan of action to carry out the threat. It is important to screen any patient making homicidal threats for suicidal ideation. If present, there is a need to implement immediate management appropriate to the level of the suicidal threat, for the safety of the patient. Eighty-five percent of patients making a homicidal threat had a previously documented psychiatric disorder, the most common being a depressive disorder. This finding differs from previous studies in which psychosis predominated. More than 60% of homicidal patients had an unrelated medical disorder requiring intervention. It is important not to overlook these medical disorders while focusing on the psychiatric needs of the patient; most of our homicidal patients proved to be cooperative in the ED setting.
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http://dx.doi.org/10.14423/SMJ.0000000000001019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6733579PMC
September 2019

Involuntary patient length-of-stay at a suburban emergency department.

Am J Emerg Med 2020 03 24;38(3):534-538. Epub 2019 May 24.

Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, United States of America.

Background: Patients who may be a danger to themselves or others often are placed on involuntary hold status in the Emergency Department (ED). Our primary objective was to determine if there are demographic and/or clinical variables of involuntary hold patients which were associated with an increased ED LOS.

Methods: Records of ED patients evaluated while on involuntary hold from January 1, 2014 through November 30, 2015 at a suburban acute-care hospital ED were reviewed. Data collected included demographics information, LOS, suicidal or homicidal ideation, suicide attempt, blood alcohol concentration (BAC), urine drug test (UDT), psychiatric disorder, substance use, medical illness, violence in the ED, and hospital admission. Linear regression based on the log of LOS was used to identify factors associated with increased LOS.

Results: Two-hundred and fifty-one patients were included in the study. ED LOS (median) was 6 h (1, 49). Linear regression analysis showed increased LOS was associated with BAC (p = 0.05), urine drug test (UDT) (p = 0.05) and UDT positive for barbiturates (p = 0.01). There was no significant difference in ED LOS with respect to age, gender, housing, psychiatric diagnosis, suicidal or homicidal ideation, suicide attempt, violence, medical diagnosis, or admission status.

Conclusions: Involuntary hold patients had an increased ED LOS associated with alcohol use, urine drug test screening, and barbiturate use. Protocol development to help stream-line ED evaluation of alcohol and drug use may improve ED LOS in this patient population.
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http://dx.doi.org/10.1016/j.ajem.2019.05.045DOI Listing
March 2020

Patients on Involuntary Hold Status in the Emergency Department.

South Med J 2019 05;112(5):265-270

From the Division of Hospital Internal Medicine, the Division of Psychiatry, and the Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida, and the Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota.

Objectives: Patients requiring involuntary holds are frequently seen in the emergency department (ED). Much of what is known comes from studies of patients at urban academic centers. Our aim was to describe the demographic and clinical characteristics of patients who were evaluated while on involuntary status at a suburban ED.

Methods: The medical records of patients seen in the ED requiring involuntary hold status between January 1, 2014 and November 30, 2015 were reviewed. Demographic and clinical variables including medical and psychiatric comorbidity were collected. A subanalysis was performed comparing patients who attempted suicide with all other involuntary patients.

Results: Two hundred fifty-one patient records were reviewed; 215 patients (85.3%) had psychiatric disorders-depression was the most common (57%)-and 108 patients (43%) had substance use disorders. Only 13 patients (5.2%) had neither a psychiatric disorder nor a history of substance use. Twenty-two patients (8.8%) were violent in the ED. Thirteen patients (5.2%) were readmitted, and 1 patient died within 30 days of discharge from the ED. One hundred twenty-four patients (49.4%) had medical disorders. Suicidal ideation was the most common reason for involuntary hold (n = 185, 73.7%); 63 patients (25.1%) attempted suicide. Compared with other involuntary patients, the patients who attempted suicide were less likely to use opiates (odds ratio 0.27, 95% confidence interval 0.08-0.94, = 0.04) and to have medical disorders (odds ratio 0.52, 95% confidence interval 0.28-0.98, = 0.04).

Conclusions: Patients in this study differed from those in urban centers with respect to sex and psychiatric disorder; however, substance misuse was common in both settings. Suicidal ideation including suicide attempt was the most common reason for involuntary status. Patients who attempted suicide were similar to other patients on involuntary hold with respect to demographic and clinical variables.
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http://dx.doi.org/10.14423/SMJ.0000000000000968DOI Listing
May 2019

Patients on Involuntary Hold Status in the Emergency Department.

South Med J 2019 05;112(5):265-270

From the Division of Hospital Internal Medicine, the Division of Psychiatry, and the Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida, and the Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota.

Objectives: Patients requiring involuntary holds are frequently seen in the emergency department (ED). Much of what is known comes from studies of patients at urban academic centers. Our aim was to describe the demographic and clinical characteristics of patients who were evaluated while on involuntary status at a suburban ED.

Methods: The medical records of patients seen in the ED requiring involuntary hold status between January 1, 2014 and November 30, 2015 were reviewed. Demographic and clinical variables including medical and psychiatric comorbidity were collected. A subanalysis was performed comparing patients who attempted suicide with all other involuntary patients.

Results: Two hundred fifty-one patient records were reviewed; 215 patients (85.3%) had psychiatric disorders-depression was the most common (57%)-and 108 patients (43%) had substance use disorders. Only 13 patients (5.2%) had neither a psychiatric disorder nor a history of substance use. Twenty-two patients (8.8%) were violent in the ED. Thirteen patients (5.2%) were readmitted, and 1 patient died within 30 days of discharge from the ED. One hundred twenty-four patients (49.4%) had medical disorders. Suicidal ideation was the most common reason for involuntary hold (n = 185, 73.7%); 63 patients (25.1%) attempted suicide. Compared with other involuntary patients, the patients who attempted suicide were less likely to use opiates (odds ratio 0.27, 95% confidence interval 0.08-0.94, = 0.04) and to have medical disorders (odds ratio 0.52, 95% confidence interval 0.28-0.98, = 0.04).

Conclusions: Patients in this study differed from those in urban centers with respect to sex and psychiatric disorder; however, substance misuse was common in both settings. Suicidal ideation including suicide attempt was the most common reason for involuntary status. Patients who attempted suicide were similar to other patients on involuntary hold with respect to demographic and clinical variables.
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http://dx.doi.org/10.14423/SMJ.0000000000000968DOI Listing
May 2019

Association between coronary angiography with or without percutaneous coronary intervention and outcomes after out-of-hospital cardiac arrest.

Resuscitation 2018 06 13;127:21-25. Epub 2018 Mar 13.

The Arizona Department of Health Services Bureau of Emergency Medical Services and Trauma System, Phoenix, AZ, United States; Arizona Emergency Medicine Research Center, The University of Arizona College of Medicine, Tucson, AZ, United States; The University of Arizona Sarver Heart Center, Tucson, AZ, United States. Electronic address:

Aim: The aim of our study was to assess the impact of coronary angiography (CAG) after out-of-hospital cardiac arrest (OHCA) without ST-elevation (STE).

Methods: Prospective observational study of adult (age ≥ 18) OHCA of presumed cardiac etiology from 1/01/2010-12/31/2014 admitted to one of 40 recognized cardiac receiving centers within a statewide resuscitation network.

Results: Among 11,976 cases, 1881 remained for analysis after exclusions. Of the 1230 non-STE cases, 524 (43%) underwent CAG with resultant PCI in 157 (30%). Survival in non-STE cases was: 56% in cases without CAG; 82% in cases with CAG but without PCI; and 78% in those with PCI (p < 0.0001). In cases without STE the aOR for survival with CAG alone was 2.34 (95% CI 1.69-3.24) and for CAG plus PCI was 1.98 (95% CI 1.26-3.09). The aOR for CPC 1/2 with CAG alone was 6.89 (95% CI 3.99-11.91) and for CAG plus PCI was 2.95 (95% CI 1.59-5.47). After propensity matching, CAG was associated with an aOR for survival of 2.10 (95% CI 1.30-3.55) and for CPC 1/2 it was 5.06 (95% CI 2.29-11.19).

Conclusion: In OHCA without STE, CAG was strongly and independently associated with survival regardless of whether PCI was performed. The association between CAG and positive outcomes remained after propensity matching.
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http://dx.doi.org/10.1016/j.resuscitation.2018.03.023DOI Listing
June 2018

Violent behavior by emergency department patients with an involuntary hold status.

Am J Emerg Med 2018 Mar 18;36(3):392-395. Epub 2017 Aug 18.

Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, FL, United States.

Background: Violence against health care workers has been increasing. Health care workers in emergency departments (EDs) are highly vulnerable because they provide care for patients who may have mental illness, behavioral problems, or substance use disorders (alone or in combination) and who are often evaluated during an involuntary hold. Our objective was to identify factors that may be associated with violent behavior in ED patients during involuntary holds.

Methods: Retrospective review of patients evaluated during an involuntary hold at a suburban acute care hospital ED from January 2014 through November 2015.

Results: Of 251 patients, 22 (9%) had violent incidents in the ED. Violent patients were more likely to have a urine drug screen positive for tricyclic antidepressants (18.2% vs 4.8%, P=0.03) and to present with substance misuse (68.2% vs 39.7%, P=0.01), specifically with marijuana (22.7% vs 9.6%, P=0.06) and alcohol (54.5% vs 24.9%, P=0.003). ED readmission rates were higher for violent patients (18.2% vs 3.9%, P=0.02). No significant difference was found between violent patients and nonviolent patients for sex, race, marital status, insurance status, medical or psychiatric condition, reason for involuntary hold, or length of stay.

Conclusion: Violent behavior by patients evaluated during an involuntary hold in a suburban acute care hospital ED was associated with tricyclic antidepressant use, substance misuse, and higher ED readmission rates.
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http://dx.doi.org/10.1016/j.ajem.2017.08.039DOI Listing
March 2018

Implementation of a Regional Telephone Cardiopulmonary Resuscitation Program and Outcomes After Out-of-Hospital Cardiac Arrest.

JAMA Cardiol 2016 06;1(3):294-302

Bureau of Emergency Medical Services & Trauma System, Arizona Department of Health Services, Phoenix.

Importance: Bystander cardiopulmonary resuscitation (CPR) significantly improves survival from out-of-hospital cardiac arrest but is provided in less than half of events on average. Telephone CPR (TCPR) can significantly increase bystander CPR rates and improve clinical outcomes.

Objective: To investigate the effect of a TCPR bundle of care on TCPR process measures and outcomes.

Design, Setting, And Participants: A prospective, before-after, observational study of adult patients with out-of-hospital cardiac arrest not receiving bystander CPR before the 9-1-1 call between October 1, 2010, and September 30, 2013.

Interventions: A TCPR program, including guideline-based protocols, telecommunicator training, data collection, and feedback, in 2 regional dispatch centers servicing metropolitan Phoenix, Arizona. Audio recordings of out-of-hospital cardiac arrest calls were audited and linked with emergency medical services and hospital outcome data.

Main Outcomes And Measures: Survival to hospital discharge and functional outcome at hospital discharge.

Results: There were 2334 out-of-hospital cardiac arrests (798 phase 1 [P1] and 1536 phase 2 [P2]) in the study group; 64% (1499) were male, and the median age was 63 years (age range, 9-101 years; interquartile range, 51-75 years). Provision of TCPR increased from 43.5% in P1 to 52.8% in P2 (P < .001), yielding an increase of 9.3% (95% CI, 4.9%-13.8%). The median time to first chest compression decreased from 256 seconds in P1 to 212 seconds in P2 (P < .001). All rhythm survival was significantly higher in P2 (184 of 1536 [12.0%]) compared with P1 (73 of 798 [9.1%]), with an adjusted odds ratio (aOR) of 1.47 (95% CI, 1.08-2.02; P = .02) in a logistic regression model and an adjusted difference in absolute survival rates (adjusted rate difference) of 3.1% (95% CI, 1.5%-4.9%). Survival for patients with a shockable initial rhythm significantly improved in P2 (107 of 306 [35.0%]) compared with P1 (42 of 170 [24.7%]), with an aOR of 1.70 (95% CI, 1.09-2.65; P = .02) and an adjusted rate difference of 9.6% (95% CI, 4.8%-14.4%). The rate of favorable functional outcome was significantly higher in P2 (127 of 1536 [8.3%]; 95% CI, 6.9%-9.8%) than in P1 (45 of 798 [5.6%]; 95% CI, 4.1%-7.5%), with an aOR of 1.68 (95% CI, 1.13-2.48; P = .01) and an adjusted rate difference of 2.7% (95% CI, 1.3%-4.4%).

Conclusions And Relevance: Implementation of a guideline-based TCPR bundle of care was independently associated with significant improvements in the provision and timeliness of TCPR, survival to hospital discharge, and survival with favorable functional outcome.
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http://dx.doi.org/10.1001/jamacardio.2016.0251DOI Listing
June 2016

Duration of Coma in Out-of-Hospital Cardiac Arrest Survivors Treated With Targeted Temperature Management.

Ann Emerg Med 2017 01 27;69(1):36-43. Epub 2016 May 27.

Arizona Emergency Medicine Research Center, University of Arizona, Phoenix, AZ; Bureau of EMS & Trauma System, Arizona Department of Health Services, Phoenix, AZ. Electronic address:

Study Objective: We evaluate the time to awakening after out-of-hospital cardiac arrest in patients treated with targeted temperature management and determine whether there was an association with any patient or event characteristics.

Methods: This was a prospective, observational cohort study of consecutive adult survivors of out-of-hospital cardiac arrest of presumed cardiac cause who were treated with targeted temperature management between January 1, 2008, and March 31, 2014. Data were obtained from hospitals and emergency medical services agencies responding to approximately 90% of Arizona's population as part of a state-sponsored out-of-hospital cardiac arrest quality improvement initiative.

Results: Among 573 out-of-hospital cardiac arrest patients who completed targeted temperature management, 316 became responsive, 60 (19.0%) of whom woke up at least 48 hours after rewarming. Eight patients (2.5%) became responsive more than 7 days after rewarming, 6 of whom were discharged with a good Cerebral Performance Category score (1 or 2). There were no differences in standard Utstein variables between the early and late awakeners. The early awakeners were more likely to be discharged with a good Cerebral Performance Category score (odds ratio 2.93; 95% confidence interval 1.09 to 7.93).

Conclusion: We found that a substantial proportion of adult out-of-hospital cardiac arrest survivors treated with targeted temperature management became responsive greater than 48 hours after rewarming, with a resultant good neurologic outcome.
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http://dx.doi.org/10.1016/j.annemergmed.2016.04.021DOI Listing
January 2017

Association between Prehospital CPR Quality and End-Tidal Carbon Dioxide Levels in Out-of-Hospital Cardiac Arrest.

Prehosp Emerg Care 2016 May-Jun;20(3):369-77. Epub 2016 Feb 1.

Introduction: International Guidelines recommend measurement of end-tidal carbon dioxide (EtCO2) to enhance cardiopulmonary resuscitation (CPR) quality and optimize blood flow during CPR. Numerous factors impact EtCO2 (e.g., ventilation, metabolism, cardiac output), yet few clinical studies have correlated CPR quality and EtCO2 during actual out-of-hospital cardiac arrest (OHCA) resuscitations. The purpose of this study was to describe the association between EtCO2 and CPR quality variables during OHCA.

Methods: This is an observational study of prospectively collected CPR quality and capnography data from two EMS agencies participating in a statewide resuscitation quality improvement program. CPR quality and capnography data from adult (≥18 years) cardiac resuscitation attempts (10/2008-06/2013) were collected and analyzed on a minute-by-minute basis using RescueNet™ Code Review. Linear mixed effect models were used to evaluate the association between (log-transformed) EtCO2 level and CPR variables: chest compression (CC) depth, CC rate, CC release velocity (CCRV), ventilation rate.

Results: Among the 1217 adult OHCA cases of presumed cardiac etiology, 925 (76.0%) had a monitor-defibrillator file with CPR quality data, of which 296 (32.0%) cases had >1 minute of capnography data during CPR. After capnography quality review, 66 of these cases (22.3%) were excluded due to uninterpretable capnography, resulting in a final study sample of 230 subjects (mean age 68 years; 69.1% male), with a total of 1581 minutes of data. After adjustment for other CPR variables, a 10 mm increase in CC depth was associated with a 4.0% increase in EtCO2 (p < 0.0001), a 10 compression/minute increase in CC rate with a 1.7% increase in EtCO2 (p = 0.02), a 10 mm/second increase in CCRV with a 2.8% increase in EtCO2 (p = 0.03), and a 10 breath/minute increase in ventilation rate with a 17.4% decrease in EtCO2 (p < 0.0001).

Conclusion: When controlling for known CPR quality variables, increases in CC depth, CC rate and CCRV were each associated with a statistically significant but clinically modest increase in EtCO2. Given the small effect sizes, the clinical utility of using EtCO2 to guide CPR performance is unclear. Further research is needed to determine the practicality and impact of using real-time EtCO2 to guide CPR delivery in the prehospital environment.
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http://dx.doi.org/10.3109/10903127.2015.1115929DOI Listing
October 2017

Measuring and improving cardiopulmonary resuscitation quality inside the emergency department.

Resuscitation 2015 Aug 8;93:8-13. Epub 2015 May 8.

Department of Emergency Medicine, University of Arizona, PO Box 245057, 1501 N. Campbell, Tucson, AZ 85724-5057, United States. Electronic address:

Aim Of Study: To evaluate CPR quality during cardiac resuscitation attempts in an urban emergency department (ED) and determine the influence of the combination of scenario-based training, real-time audiovisual feedback (RTAVF), and post-event debriefing on CPR quality.

Methods: CPR quality was recorded using an R Series monitor-defibrillator (ZOLL Medical) during the treatment of adult cardiac arrest patients. Phase 1 (P1; 11/01/2010-11/15/2012) was an observation period of CPR quality. Phase 2 (P2; 11/15/2012-11/08/2013) was after a 60-min psychomotor skills CPR training and included RTAVF and post-event debriefing.

Results: A total of 52 cardiac arrest patients were treated in P1 (median age 56 yrs, 63.5% male) and 49 in P2 (age 60 yrs, 83.7% male). Chest compression (CC) depth increased from 46.7 ± 3.8mm in P1 to 61.6 ± 2.8mm in P2 (p < 0.001), with the percentage of CC ≥ 51 mm increasing from 30.6% in P1 to 87.4% in P2 (p < 0.001). CC release velocity increased from 314 ± 25 mm/s in P1 to 442 ± 20 mm/s in P2 (p < 0.001). No significant differences were identified in CC fraction (84.3% P1 vs. 88.4% P2, p = 0.1), CC rate (125 ± 3 cpm P1 vs. 125 ± 3 cpm P2, p = 0.7), or pre-shock pause (9.7s P1 vs. 5.9s P2, p = 0.5), though CC fraction and pre-shock pause were within guideline recommendations.

Conclusion: Implementation of the bundle of scenario-based training, real-time audiovisual CPR feedback, and post-event debriefing was associated with improved CPR quality and compliance with CPR guidelines in this urban teaching emergency department.
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http://dx.doi.org/10.1016/j.resuscitation.2015.04.031DOI Listing
August 2015

Chest compression release velocity: Association with survival and favorable neurologic outcome after out-of-hospital cardiac arrest.

Resuscitation 2015 Jul 29;92:107-14. Epub 2015 Apr 29.

University of Arizona College of Medicine-Phoenix, 550 E Van Buren St., Phoenix, AZ 85004, United States; Department of Emergency Medicine, University of Arizona, PO Box 245057, 1501 N. Campbell, Tucson, AZ 85724-5057, United States; Bureau of Emergency Medical Services and Trauma System, Arizona Department of Health Services, 150 N. 18th Avenue, #540, Phoenix, AZ 85007-3248, United States. Electronic address:

Purpose: We evaluated the association between chest compression release velocity (CCRV) and outcomes after out-of-hospital cardiac arrest (OHCA).

Materials And Methods: CPR quality was measured using a defibrillator with accelerometer-based technology (E Series, ZOLL Medical) during OHCA resuscitations by 2 EMS agencies in Arizona between 10/2008 and 06/2013. All non-EMS-witnessed adult (≥ 18 years) arrests of presumed cardiac etiology were included. The association between mean CCRV (assessed as an appropriate measure of central tendency) and both survival to hospital discharge and neurologic outcome (Cerebral Performance Category score = 1 or 2) was analyzed using multivariable logistic regression to control for known and potential confounders and multiple imputation to account for missing data.

Results: 981 OHCAs (median age 68 years, 65% male, 11% survival to discharge) were analyzed with 232 (24%) missing CPR quality data. All-rhythms survival varied significantly with CCRV [fast (≥ 400 mm/s) = 18/79 (23%); moderate (300-399.9 mm/s) = 50/416 (12%); slow (<300 mm/s) 17/255 (7%); p < 0.001], as did favorable neurologic outcome [fast = 14/79 (18%); moderate = 43/415 (10%); slow = 11/255 (4%); p < 0.001]. Fast CCRV was associated with increased survival compared to slow [adjusted odds ratio (aOR) 4.17 (95% CI: 1.61, 10.82) and moderate CCRV [aOR 3.08 (1.39, 6.83)]. Fast CCRV was also associated with improved favorable neurologic outcome compared to slow [4.51 (1.57, 12.98)]. There was a 5.2% increase in the adjusted odds of survival for each 10mm/s increase in CCRV [aOR 1.052 (1.001, 1.105)].

Conclusion: CCRV was independently associated with improved survival and favorable neurologic outcome at hospital discharge after adult OHCA.
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http://dx.doi.org/10.1016/j.resuscitation.2015.04.026DOI Listing
July 2015

Analysis of out-of-hospital cardiac arrest location and public access defibrillator placement in Metropolitan Phoenix, Arizona.

Resuscitation 2015 Apr 22;89:43-9. Epub 2015 Jan 22.

Arizona Department of Health Services Bureau of Emergency Medical Services and Trauma System, Phoenix, AZ, United States; Arizona Emergency Medicine Research Center, University of Arizona College of Medicine, Tucson, AZ, United States; Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ, United States.

Objectives: Automated external defibrillators (AEDs) improve outcomes from out-of-hospital cardiac arrest (OHCA) but are infrequently used. We sought to compare the locations of OHCAs and AEDs in metropolitan Phoenix, Arizona.

Methods: Public location OHCAs and AEDs were geocoded utilizing a statewide OHCA database (1/2010-12/2012) and AED registry. OHCAs were mapped using kernel-density estimation and overlapped with AED placements. Spearman's rho was obtained to determine the correlation between OHCA incidents and AED locations.

Results: A total of 654 consecutive public location OHCAs and all 1704 non-medical facility AEDs registered in the study area were included in the analysis. High OHCA incident areas lacking AEDs were identified in the kernel-density surface map. OHCA event/AED correlation analysis showed a weak correlation (Spearman's rho=0.283; p=0.002). Events occurred most frequently at locations categorized as "In Cars/Roads/Parking lots" (190/654, 29.1%) and there were no identified AEDs for these areas. AEDs were placed most frequently in "Public business/Office/Workplace" and cardiac arrests occurred with the second highest frequency in this location type.

Conclusion: There was a weak correlation between OHCA events and deployed AEDs. It was possible to identify areas where OHCAs occurred frequently but AEDs were lacking. The ability to correlate the sites of OHCAs and AED locations is a necessary step toward improving the effectiveness of public access defibrillation.
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http://dx.doi.org/10.1016/j.resuscitation.2014.10.029DOI Listing
April 2015

Therapeutic hypothermia and targeted temperature management after cardiac arrest.

JAMA Neurol 2014 Dec;71(12):1577-8

Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida.

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http://dx.doi.org/10.1001/jamaneurol.2014.3125DOI Listing
December 2014

Disparities in bystander CPR provision and survival from out-of-hospital cardiac arrest according to neighborhood ethnicity.

Am J Emerg Med 2014 Sep 24;32(9):1041-5. Epub 2014 Jun 24.

Arizona Emergency Medicine Research Center, University of Arizona College of Medicine, Tucson, AZ.

Study Objective: We aimed to determine if there are differences in bystander cardiopulmonary resuscitation (BCPR) provision and survival to hospital discharge from out-of-hospital cardiac arrest (OHCA) occurring in Hispanic neighborhoods in Arizona.

Methods: We analyzed a prospectively collected, statewide Utstein-compliant OHCA database between January 1, 2010, and December 31, 2012. Cases of OHCA were geocoded to determine their census tract of event location, and their neighborhood main ethnicity was assigned using census data. Neighborhoods were classified as "Hispanic" or "non-Hispanic white" when the percentage of residents in the census tract was 80% or more.

Results: Among the 6637 geocoded adult OHCA victims during the study period, 4821 cases were included in this analysis, after excluding 1816 cases due to incident location, traumatic cause, or because the arrest occurred after emergency medical service arrival. In OHCAs occurring at Hispanic neighborhoods as compared with non-Hispanic white neighborhoods, the provision of BCPR (28.6% vs 43.8%; P < .001) and initially monitored shockable rhythm (17.3% vs 25.7%; P < .006) was significantly less frequent. Survival to hospital discharge was significantly lower in Hispanic neighborhoods than in non-Hispanic white neighborhoods (4.9% vs 10.8%; P = .013). The adjusted odds ratio (OR) of Hispanic neighborhood for BCPR provision (OR, 0.62; 95% confidence interval, 0.44-0.89) was lower as compared with non-Hispanic white neighborhoods.

Conclusions: In Arizona, OHCA patients in Hispanic neighborhoods received BCPR less frequently and had a lower survival to hospital discharge rate than those in non-Hispanic white neighborhoods. Public health efforts to attenuate this disparity are needed.
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http://dx.doi.org/10.1016/j.ajem.2014.06.019DOI Listing
September 2014

The influence of scenario-based training and real-time audiovisual feedback on out-of-hospital cardiopulmonary resuscitation quality and survival from out-of-hospital cardiac arrest.

Ann Emerg Med 2013 Jul 7;62(1):47-56.e1. Epub 2013 Mar 7.

Department of Health Services, University of Arizona College of Medicine, Phoenix, AZ, USA.

Study Objective: We assess whether an initiative to optimize out-of-hospital provider cardiopulmonary resuscitation (CPR) quality is associated with improved CPR quality and increased survival from out-of-hospital cardiac arrest.

Methods: This was a before-after study of consecutive adult out-of-hospital cardiac arrest. Data were obtained from out-of-hospital forms and defibrillators. Phase 1 included 18 months with real-time audiovisual feedback disabled (October 2008 to March 2010). Phase 2 included 16 months (May 2010 to September 2011) after scenario-based training of 373 professional rescuers and real-time audiovisual feedback enabled. The effect of interventions on survival to hospital discharge was assessed with multivariable logistic regression. Multiple imputation of missing data was used to analyze the effect of interventions on CPR quality.

Results: Analysis included 484 out-of-hospital cardiac arrest patients (phase 1 232; phase 2 252). Median age was 68 years (interquartile range 56-79); 66.5% were men. CPR quality measures improved significantly from phase 1 to phase 2: Mean chest compression rate decreased from 128 to 106 chest compressions per minute (difference -23 chest compressions; 95% confidence interval [CI] -26 to -19 chest compressions); mean chest compression depth increased from 1.78 to 2.15 inches (difference 0.38 inches; 95% CI 0.28 to 0.47 inches); median chest compression fraction increased from 66.2% to 83.7% (difference 17.6%; 95% CI 15.0% to 20.1%); median preshock pause decreased from 26.9 to 15.5 seconds (difference -11.4 seconds; 95% CI -15.7 to -7.2 seconds), and mean ventilation rate decreased from 11.7 to 9.5/minute (difference -2.2/minute; 95% CI -3.9 to -0.5/minute). All-rhythms survival increased from phase 1 to phase 2 (20/231, 8.7% versus 35/252, 13.9%; difference 5.2%; 95% CI -0.4% to 10.8%), with an adjusted odds ratio of 2.72 (95% CI 1.15 to 6.41), controlling for initial rhythm, witnessed arrest, age, minimally interrupted cardiac resuscitation protocol compliance, and provision of therapeutic hypothermia. Witnessed arrests/shockable rhythms survival was 26.3% (15/57) for phase 1 and 55.6% (20/36) for phase 2 (difference 29.2%; 95% CI 9.4% to 49.1%).

Conclusion: Implementation of resuscitation training combined with real-time audiovisual feedback was independently associated with improved CPR quality, an increase in survival, and favorable functional outcomes after out-of-hospital cardiac arrest.
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http://dx.doi.org/10.1016/j.annemergmed.2012.12.020DOI Listing
July 2013

CPR variability during ground ambulance transport of patients in cardiac arrest.

Resuscitation 2013 May 21;84(5):592-5. Epub 2012 Nov 21.

Maricopa Medical Center, Phoenix, AZ, USA.

Aim Of Study: High-quality CPR is associated with improved outcomes from out-of-hospital cardiac arrest (OHCA). The purpose of this investigation was to compare the quality of CPR provided at the prehospital scene, during ambulance transport, and during the early minutes in the emergency department (ED).

Methods: A prospective observational review of consecutive adult patients with non-traumatic OHCA was conducted between September 2008 and February 2010. Patients with initiation of prehospital CPR were included as part of a statewide cardiac resuscitation quality improvement program. A monitor-defibrillator with accelerometer-based CPR measurement capability (E-series, ZOLL Medical) was utilized. CPR quality measures included variability in chest compression (CC) depth and rate, mean depth and rate, and the CC fraction. Variability of CC was defined as the mean of minute-to-minute standard deviation in CC depth or rate. CC fraction was defined as the percent of time that CPR was being performed when appropriate throughout resuscitation.

Results: Fifty-seven adult patients with OHCA had electronic CPR data recorded at the scene, in the ambulance, and upon arrival in the ED. Across time periods, there was increased variability in CC depth (scene: 0.20 in.; transport: 0.26 in.; ED: 0.31 in., P<0.01) and rate (scene: 18.2 CC min(-1); transport: 26.1 CC min(-1); ED: 26.3 CC min(-1), P<0.01). The mean CC depth, rate, and the CC fraction did not differ significantly between groups.

Conclusions: There was increased CC variability from the prehospital scene to the ED though there was no difference in mean CC depth, rate, or in CC fraction. The clinical significance of CC variability remains to be determined.
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http://dx.doi.org/10.1016/j.resuscitation.2012.07.042DOI Listing
May 2013

Chest compression-only cardiopulmonary resuscitation performed by lay rescuers for adult out-of-hospital cardiac arrest due to non-cardiac aetiologies.

Resuscitation 2013 Apr 1;84(4):435-9. Epub 2012 Sep 1.

Arizona Emergency Medicine Research Center, Department of Emergency Medicine, University of Arizona, Tucson, AZ 85724, USA.

Objective: Bystander CPR improves survival in patients with out-of-hospital cardiac arrest (OHCA). For adult sudden collapse, bystander chest compression-only CPR (COCPR) is recommended in some circumstances by the American Heart Association and European Resuscitation Council. However, adults who arrest from non-cardiac causes may also receive COCPR. Because rescue breathing may be more important for individuals suffering OHCA secondary to non-cardiac causes, COCPR is not recommended for these cases. We evaluated the relationship of lay rescuer COCPR and survival after OHCA from non-cardiac causes.

Methods: Analysis of a statewide Utstein-style registry of adult OHCA, during a large scale campaign endorsing COCPR for OHCA from presumed cardiac cause. The relationship between lay rescuer CPR (both conventional CPR and COCPR) and survival to hospital discharge was evaluated.

Results: Presumed non-cardiac aetiologies of OHCA accounted for 15% of all cases, and lay rescuer CPR was provided in 29% of these cases. Survival to hospital discharge occurred in 3.8% after conventional CPR, 2.7% after COCPR, and 4.0% after no CPR (p=0.85). The proportion of patients receiving COCPR was much lower in the cohort of OHCA from respiratory causes (8.3%) than for those with presumed cardiac OHCA (18.0%; p<0.001).

Conclusions: In the setting of a campaign endorsing lay rescuer COCPR for cardiac OHCA, bystanders were less likely to perform COCPR on OHCA victims who might benefit from rescue breathing.
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http://dx.doi.org/10.1016/j.resuscitation.2012.07.038DOI Listing
April 2013

Impact of a high body mass index on lower extremity injury in marathon/half-marathon participants.

J Phys Act Health 2012 Jan;9(1):96-103

Mayo Clinic, Jacksonville, FL, USA.

Background: To evaluate whether a high body mass index (BMI) predisposes marathon/half-marathon participants to lower extremity injuries.

Methods: Consenting adult participants at the 2008 National Marathon to Fight Breast Cancer were enrolled in this observational study. The primary outcome measure was prevalence of self-reported lower extremity injury, during both training and race participation, with respect to BMI.

Results: There were 194 subjects with complete data: 139 females (72%) and 55 males. Forty-six percent of females and 51% of males ran the full marathon (P = .63). Median BMI was 23.7 kg/m(2) for females and 26.2 kg/m(2) for males (P = .001). Eleven (24%) females in BMI tertile 1 (T1) suffered a training injury, while 9 (18%) from T2 and 4 (9%) from T3 suffered injuries (P = .072; OR 0.89; 95% CI 0.78 to 1.01). Twenty-six (19%) females suffered an injury during the race. Females in T1 were more likely to suffer a race-related injury (P = .038; OR 0.87; 95% CI 0.77 to 0.99). Females were 13% less likely to suffer a race-related injury with each 1-unit increase in BMI. Rates of injury did not differ by BMI tertile in males.

Conclusions: A high BMI did not impart an increased risk of lower extremity injury during training or race participation.
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http://dx.doi.org/10.1123/jpah.9.1.96DOI Listing
January 2012

The effectiveness of ultrabrief and brief educational videos for training lay responders in hands-only cardiopulmonary resuscitation: implications for the future of citizen cardiopulmonary resuscitation training.

Circ Cardiovasc Qual Outcomes 2011 Mar 8;4(2):220-6. Epub 2011 Mar 8.

Department of Emergency Medicine and Resuscitation Science Center, Maricopa Medical Center, Phoenix, AZ 85008, USA.

Background: Bystander cardiopulmonary resuscitation (CPR) improves survival from out-of-hospital cardiac arrest (OHCA) but often is not performed. We hypothesized that subjects viewing very short Hands-Only CPR videos will (1) be more likely to attempt CPR in a simulated OHCA scenario and (2) demonstrate better CPR skills than untrained individuals.

Methods And Results: This study is a prospective trial of 336 adults without recent CPR training randomized into 4 groups: (1) control (no training) (n=51); (2) 60-second video training (n=95); (3) 5-minute video training (n=99); and (4) 8-minute video training, including manikin practice (n=91). All subjects were tested for their ability to perform CPR during an adult OHCA scenario using a CPR-sensing manikin and Laerdal PC SkillReporting software. One half of the trained subjects were randomly assigned to testing immediately and the other half after a 2-month delay. Twelve (23.5%) controls did not even attempt CPR, which was true of only 2 subjects (0.7%; P=0.01) from any of the experimental groups. All experimental groups had significantly higher average compression rates (closer to the recommended 100/min) than the control group (P<0.001), and all experimental groups had significantly greater average compression depth (>38 mm) than the control group (P<0.0001).

Conclusions: Laypersons exposed to very short Hands-Only CPR videos are more likely to attempt CPR and show superior CPR skills than untrained laypersons. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT01191736.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.110.959353DOI Listing
March 2011

Chest compression-only CPR by lay rescuers and survival from out-of-hospital cardiac arrest.

JAMA 2010 Oct;304(13):1447-54

Arizona Department of Health Services, 150 N 18th Ave, Ste 540, Phoenix, AZ 85007, USA.

Context: Chest compression-only bystander cardiopulmonary resuscitation (CPR) may be as effective as conventional CPR with rescue breathing for out-of-hospital cardiac arrest.

Objective: To investigate the survival of patients with out-of-hospital cardiac arrest using compression-only CPR (COCPR) compared with conventional CPR.

Design, Setting, And Patients: A 5-year prospective observational cohort study of survival in patients at least 18 years old with out-of-hospital cardiac arrest between January 1, 2005, and December 31, 2009, in Arizona. The relationship between layperson bystander CPR and survival to hospital discharge was evaluated using multivariable logistic regression.

Main Outcome Measure: Survival to hospital discharge.

Results: Among 5272 adults with out-of-hospital cardiac arrest of cardiac etiology not observed by responding emergency medical personnel, 779 were excluded because bystander CPR was provided by a health care professional or the arrest occurred in a medical facility. A total of 4415 met all inclusion criteria for analysis, including 2900 who received no bystander CPR, 666 who received conventional CPR, and 849 who received COCPR. Rates of survival to hospital discharge were 5.2% (95% confidence interval [CI], 4.4%-6.0%) for the no bystander CPR group, 7.8% (95% CI, 5.8%-9.8%) for conventional CPR, and 13.3% (95% CI, 11.0%-15.6%) for COCPR. The adjusted odds ratio (AOR) for survival for conventional CPR vs no CPR was 0.99 (95% CI, 0.69-1.43), for COCPR vs no CPR, 1.59 (95% CI, 1.18-2.13), and for COCPR vs conventional CPR, 1.60 (95% CI, 1.08-2.35). From 2005 to 2009, lay rescuer CPR increased from 28.2% (95% CI, 24.6%-31.8%) to 39.9% (95% CI, 36.8%-42.9%; P < .001); the proportion of CPR that was COCPR increased from 19.6% (95% CI, 13.6%-25.7%) to 75.9% (95% CI, 71.7%-80.1%; P < .001). Overall survival increased from 3.7% (95% CI, 2.2%-5.2%) to 9.8% (95% CI, 8.0%-11.6%; P < .001).

Conclusion: Among patients with out-of-hospital cardiac arrest, layperson compression-only CPR was associated with increased survival compared with conventional CPR and no bystander CPR in this setting with public endorsement of chest compression-only CPR.
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http://dx.doi.org/10.1001/jama.2010.1392DOI Listing
October 2010

Persistent ventricular fibrillation during therapeutic hypothermia and prolonged high-dose vasopressor therapy: case report.

J Emerg Med 2012 Jul 13;43(1):36-40. Epub 2009 Aug 13.

Kansas City University of Medicine and Biosciences, Kansas City, Missouri, USA.

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.
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http://dx.doi.org/10.1016/j.jemermed.2009.05.027DOI Listing
July 2012

Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest.

Ann Emerg Med 2009 Nov 6;54(5):656-662.e1. Epub 2009 Aug 6.

Arizona Department of Health Services Bureau of Emergency Medical Services and Trauma System, Phoenix, AZ, USA.

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.
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http://dx.doi.org/10.1016/j.annemergmed.2009.06.011DOI Listing
November 2009

Effect of transport interval on out-of-hospital cardiac arrest survival in the OPALS study: implications for triaging patients to specialized cardiac arrest centers.

Ann Emerg Med 2009 Aug 23;54(2):248-55. Epub 2009 Jan 23.

Arizona Emergency Medicine Research Center, Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ.

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.
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http://dx.doi.org/10.1016/j.annemergmed.2008.11.020DOI Listing
August 2009

Methicillin-resistant Staphylococcus aureus sepsis presenting with septic pulmonary emboli.

J Emerg Med 2009 Nov 23;37(4):383-5. Epub 2008 Aug 23.

Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida, USA.

Background: Septic pulmonary emboli are the result of infections that typically originate from an extrapulmonary source. Septic pulmonary embolus is a rare disorder that classically presents with fever, respiratory symptoms, and lung infiltrates.

Objectives: Our objective is to share our experience of a rare diagnosis that was the result of a very common bacterium seen in the Emergency Department (ED).

Case Report: We present a case of methicillin-resistant Staphylococcus aureus (MRSA) sepsis presenting as bilateral septic pulmonary emboli in a patient with undiagnosed acquired immunodeficiency syndrome. A 29-year-old Hispanic man presented to our ED with a history of abdominal pain and vomiting for 3 days and new onset of shortness of breath. The patient was seen 2 weeks prior for a simple abscess incision and drainage and was treated with trimethoprim/sulfamethoxazole. On the day of admission, a helical computed tomography scan of the chest was obtained, which revealed bilateral septic pulmonary emboli. The patient was admitted for intravenous antibiotic therapy and was subsequently found to have MRSA sepsis.

Conclusion: Septic pulmonary embolus is a rare finding that is most commonly seen in patients who are immunocompromised. The patient fully recovered after aggressive antibiotic therapy.
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http://dx.doi.org/10.1016/j.jemermed.2007.12.029DOI Listing
November 2009

The impact of prehospital transport interval on survival in out-of-hospital cardiac arrest: implications for regionalization of post-resuscitation care.

Resuscitation 2008 Oct 9;79(1):61-6. Epub 2008 Jul 9.

Arizona Resuscitation Research Institute, Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ 85724, USA.

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.
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http://dx.doi.org/10.1016/j.resuscitation.2008.05.006DOI Listing
October 2008
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