Arthur B Sanders

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Scholarly Contributions

Books

• Sanders, A. B. (2015). Strategies to Improve Cardiac Arrest Survival.. The National Academies Press.

Chapters

• Sanders, A. B. (2018). Hypertensive Emergencies. In Griffith’s Five Minutes Clinical Consultant. Philadelphia: Lea and Febiger.
• Sanders, A. B. (2014). General Approach to the Geriatric Patient. In Geriatric Emergency Medicine. Cambridge University Press, Cambridge UK.
• Stolz, L. A., & Sanders, A. B. (2013). Delirium. In Rosen and Barkin's 5-Minute Emergency Medicine Clinical Consult, 5th edition. Philadelphia: Lippincott, Williams and Wilkins.
• Carpenter, C., Stern, M. E., & Sanders, A. B. (2009). Caring for the Elderly. In XX. Wiley-Blackwell. doi:10.1002/9781444303674.CH25

Journals/Publications

• Sanders, A. B. (2018). Point of care Head and Neck Sonography for Clinical Problem-Solving: Impact of One-day Training Sessions of Medical Student Education. Cureus, Cureus 10(12): e3740DOI 10.7759/cureus.3740.
• Stea, N., Thompson, M., Stolz, L. A., Stea, N., Sanders, A. B., Patanwala, A. E., Hawbaker, N., Breshears, E., Amini, R., & Adhikari, S. (2017). Assessment of ultrasound-guided procedures in preclinical years.. Internal and emergency medicine, 12(7), 1025-1031. doi:10.1007/s11739-016-1525-4
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  Medical graduates entering residency often lack confidence and competence in procedural skills. Implementation of ultrasound (US)-guided procedures into undergraduate medical education is a logical step to addressing medical student procedural competency. The objective of our study was to determine the impact of an US teaching workshop geared toward training medical students in how to perform three distinct US-guided procedures. Cross-sectional study at an urban academic medical center. Following a 1-h didactic session, a sample of 11 students out of 105 (10.5 %) were asked to perform three procedures each (total 33 procedures) to establish a baseline of procedural proficiency. Following a 1-h didactic session, students were asked to perform 33 procedures using needle guidance with ultrasound to establish a baseline of student proficiency. Also, a baseline survey regarding student opinions, self-assessment of skills, and US procedure knowledge was administered before and after the educational intervention. After the educational workshop, students' procedural competency was assessed by trained ultrasound clinicians. One-hundred-and-five third-year medical students participated in this study. The average score for the knowledge-based test improved from 46 % (SD 16 %) to 74 % (SD 14 %) (p < 0.05). Students' overall confidence in needle guidance improved from 3.1 (SD 2.4) to 7.8 (SD 1.5) (p < 0.05). Student assessment of procedural competency using an objective and validated assessment tool demonstrated statistically significant (p < 0.05) improvement in all procedures. The one-day US education workshop employed in this study was effective at immediately increasing third-year medical students' confidence and technical skill at performing US-guided procedures.
• Amini, R., Stolz, L. A., Hernandez, N. C., Gaskin, K., Baker, N., Sanders, A. B., & Adhikari, S. (2016). Sonography and hypotension: a change to critical problem solving in undergraduate medical education. Advances in medical education and practice, 7, 7-13.
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  Multiple curricula have been designed to teach medical students the basics of ultrasound; however, few focus on critical problem-solving. The objective of this study is to determine whether a theme-based ultrasound teaching session, dedicated to the use of ultrasound in the management of the hypotensive patient, can impact medical students' ultrasound education and provide critical problem-solving exercises.
• Rhodes, S. M., Patanwala, A. E., Cremer, J. K., Marshburn, E. S., Herman, M., Shirazi, F. M., Harrison-Monroe, P., Wendel, C., Fain, M., Mohler, J., & Sanders, A. B. (2016). Predictors of Prolonged Length of Stay and Adverse Events among Older Adults with Behavioral Health-Related Emergency Department Visits: A Systematic Medical Record Review. The Journal of emergency medicine, 50(1), 143-52.
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  Behavioral health (BH)-related visits to the emergency department (ED) by older adults are increasing. This population has unique challenges to providing quality, timely care.
• Drummond, B. S., Stolz, L. A., Sanders, A. B., Reilly, K. M., Panchal, A. R., O'brien, K., Gross, A., Drummond, B. S., Chan, L., Amini, R., & Adhikari, S. (2015). Theme-based teaching of point-of-care ultrasound in undergraduate medical education.. Internal and emergency medicine, 10(5), 613-8. doi:10.1007/s11739-015-1222-8
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  A handful of medical schools have developed formal curricula to teach medical students point-of-care ultrasound; however, no ideal method has been proposed. The purpose of this study was to assess an innovative theme-based ultrasound educational model for undergraduate medical education. This was a single-center cross-sectional study conducted at an academic medical center. The study participants were 95 medical students with minimal or no ultrasound experience during their third year of training. The educational theme for the ultrasound session was "The evaluation of patients involved in motor vehicle collisions." This educational theme was carried out during all components of the 1-day event called SonoCamp: asynchronous learning, the didactic lecture, the skills stations, the team case challenge and the individual challenge stations. Assessment consisted of a questionnaire, team case challenge, and individual challenges. A total of 89 of 95 (94 %) students who participated in SonoCamp responded, and 92 % (87 of 95) completed the entire questionnaire before and after the completion of SonoCamp. Ninety-nine percent (95 % CI, 97-100 %) agreed that training at skill stations helped solidify understanding of point-of-care ultrasound. Ninety-two percent (95 % CI, 86-98 %) agreed that theme-based learning is an engaging learning style for point-of-care ultrasound. All students agreed that having a team exercise is an engaging way to learn point-of-care ultrasound; and of the 16 groups, the average score on the case-based questions was 82 % (SD + 28). The 1-day, theme-based ultrasound educational event was an engaging learning technique at our institution which lacks undergraduate medical education ultrasound curriculum.
• Ewy, G. A., Bobrow, B. J., Chikani, V., Sanders, A. B., Otto, C. W., Spaite, D. W., & Kern, K. B. (2015). The time dependent association of adrenaline administration and survival from out-of-hospital cardiac arrest. Resuscitation, 96, 180-5.
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  Recommended for decades, the therapeutic value of adrenaline (epinephrine) in the resuscitation of patients with out-of-hospital cardiac arrest (OHCA) is controversial.
• Mhayamaguru, K. M., Means, R., Sanders, A. B., & Amini, R. (2015). Vaginal bulge. The western journal of emergency medicine, 16(3), 424-5.
• Thompson, M., Stolz, L. A., Stea, N., Sanders, A. B., Hawbaker, N., Breshears, E., Amini, R., & Adhikari, S. (2015). 168 SNAPPY Teaching and Assessing Medical Students: Sonographic Assistance for Procedures in Preclinical Years. Annals of Emergency Medicine, 66(4), S60. doi:10.1016/j.annemergmed.2015.07.200
• Baker, N., Stolz, L. A., Sanders, A. B., Gaskin, K., Baker, N., Amini, R., & Adhikari, S. (2014). 320 Evaluation of Hypotension: A Theme-Based Approach to Teaching Point-of-Care Ultrasound to Medical Students. Annals of Emergency Medicine, 64(4), S113-S114. doi:10.1016/j.annemergmed.2014.07.348
• Bakhsh, H. T., Perona, S. J., Shields, W. A., Salek, S., Sanders, A. B., & Patanwala, A. E. (2014). Medication errors in psychiatric patients boarded in the emergency department. The International journal of risk & safety in medicine, 26(4), 191-8.
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  Patients boarded in the emergency department (ED) with psychiatric complaints may be at risk for medication errors. However, no studies exist to characterize the types of errors and risk factors for errors in these patients.
• Bobrow, B. J., Zuercher, M., Spaite, D. W., Sanders, A. B., Otto, C. W., Kern, K. B., Ewy, G. A., Chikani, V., & Bobrow, B. J. (2014). Abstract 110: The Association Between the Timing of Epinephrine (Adrenalin) Administration and Survival from Out-of-Hospital Ventricular Fibrillation Arrest. Circulation.
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  Introduction: The benefit of epinephrine administration by emergency medical services providers (EMS) during resuscitation of patients with out-of-hospital-cardiac arrest (OHCA) is controversial. To address the association of the timing of epinephrine administration and outcome, we accessed the Save Hearts in Arizona Register and Educational (SHARE) program registry, and analyzed the time between 9-1-1 dispatches, the first dose of epinephrine and survival to hospital discharge. Methods: A retrospective analysis of prospectively collected statewide OHCA data using the SHARE database between October 2004 and December 2013. Results: There were 2,213 OHCA with a shockable initial rhythm who received epinephrine by EMS. Logistic regression was performed adjusted for age, gender, witnessed, bystander CPR, arrival time (dispatch to scene), and dispatch to defibrillation time, year, and method of ventilation. Of these, 396 (17.8%) survived to discharge. The times from dispatch to first epinephrine administration...
• Cohn, B., Keim, S. M., & Sanders, A. B. (2014). Can anticoagulated patients be discharged home safely from the emergency department after minor head injury?. The Journal of emergency medicine, 46(3), 410-7.
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  Anticoagulated patients have increased risk for bleeding, and serious outcomes could occur after head injury. Controversy exists regarding the utility of head computed tomography (CT) in allowing safe discharge dispositions for anticoagulated patients suffering minor head injury.
• Spaite, D. W., Bobrow, B. J., Stolz, U., Berg, R. A., Sanders, A. B., Kern, K. B., Chikani, V., Humble, W., Mullins, T., Stapczynski, J. S., Ewy, G. A., & , A. C. (2014). Statewide regionalization of postarrest care for out-of-hospital cardiac arrest: association with survival and neurologic outcome. Annals of emergency medicine, 64(5), 496-506.e1.
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  For out-of-hospital cardiac arrest, authoritative, evidence-based recommendations have been made for regionalization of postarrest care. However, system-wide implementation of these guidelines has not been evaluated. Our hypothesis is that statewide regionalization of postarrest interventions, combined with emergency medical services (EMS) triage bypass, is associated with improved survival and neurologic outcome.
• Stephens, J. A., Sanders, A. B., Panchal, B. D., Panchal, A. R., & Goldberg, L. C. (2014). Abstract 123: Survey Analysis of a Statewide CPR Initiative: Willingness in Comparison to Median Income and Training. Circulation, 130.
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  Background: Bystander CPR is provided in ~25% of out of hospital cardiac arrests in the US. To improve this low rate, the Save Hearts in Arizona Registry & Education program has initiated a multifaceted, statewide public chest compression only (CCO) CPR education campaign. It is unclear whether a statewide CCO-CPR campaign changes the intention of bystanders to perform CPR. It’s further unknown if this initiative affects willingness in populations with lowest survival and CPR performance. Objective: Evaluate the willingness to perform CPR, in various income demographics, following a statewide CPR intervention. Methods: Adult Arizona residents were surveyed at an academic medical center regarding performing CPR. They were asked their attitudes and feelings concerning performing CPR on strangers and family. Demographics were collected including age, gender, education, race and zip code which was used to incorporate census data for median income (separated as quartiles). Inclusion criteria were Arizona residents, age >18, and missing < 10% of survey data. CPR training was defined as CCO or formal CPR training. Results: Total of 1302 surveys were collected with a final population of 1163. Mean age was 40 yo (95% CI: 38.8, 40.5) with 44% males (95% CI: 41, 47). Willingness to perform CCO-CPR on strangers or family was high at 84% and 92%, respectively. However, when evaluated against median income, individuals in the lower income quartiles were less likely to perform CPR compared to higher quartiles for both strangers (77%; 95% CI 73, 82; P = 0.003) and family (90%; 95% CI 87, 94; P = 0.025). In these lower quartiles, a third as many individuals received training in CPR compared to the higher quartiles (p
• Bobrow, B. J., Stolz, U., Vadeboncoeur, T. F., Stolz, U., Spaite, D. W., Sanders, A. B., Panchal, A. R., Kern, K. B., Ewy, G. A., Bobrow, B. J., & Berg, R. A. (2013). Chest compression-only cardiopulmonary resuscitation performed by lay rescuers for adult out-of-hospital cardiac arrest due to non-cardiac aetiologies.. Resuscitation, 84(4), 435-9. doi:10.1016/j.resuscitation.2012.07.038
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  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..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..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
• Chan, L., Drummond, B. S., Stolz, L. A., Sanders, A. B., Reilly, K. M., Panchal, A. R., O'brien, K., Gross, A., Drummond, B. S., Chan, L., Amini, R., & Adhikari, S. (2013). Theme-Based Ultrasound Education: A Novel Approach to Teaching Point-of-Care Ultrasound to Medical Students. Annals of Emergency Medicine, 62(4), S136. doi:10.1016/j.annemergmed.2013.07.206
• Rappaport, D., Chuu, A., Hullett, C., Nematollahi, S., Teeple, M., Bhuyan, N., Honkanen, I., Adamas-Rappaport, W. J., & Sanders, A. (2013). Assessment of alcohol withdrawal in native American patients utilizing the Clinical Institute Withdrawal Assessment of Alcohol Revised scale. Journal of Addiction Medicine, 7(3), 196-199.
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  PMID: 23579238;Abstract: Background: The Clinical Institute Withdrawal Assessment of Alcohol Revised (CIWA-Ar) is a commonly used scale for assessing the severity of alcohol withdrawal syndrome in the acute setting. Despite validation of this scale in the general population, the effect of ethnicity on CIWA-Ar scoring does not appear in the literature. The purpose of our study was to investigate the validity of the CIWA-Ar scale among Native American patients evaluated for acute alcohol detoxification. Methods: A case series of all patients seen for alcohol withdrawal at an Acute Drug and Alcohol Detoxification facility was conducted from June 1, 2011, until April 1, 2012. The CIWA-Ar scores were recorded by trained nursing staff on presentation to Triage Department and every 2 hours thereafter. At our institution, a score of 10 or greater indicates the need for inpatient hospital admission and treatment. Ethnicity was self-reported. Age, sex, blood alcohol concentration, blood pressure, and pulse were recorded on presentation and vital signs repeated every 2 hours. Patients were excluded from the study if other drug use was noted by history or initial urine drug screen. A multivariate logistic regression model was utilized to identify statistically significant variables associated with admission to the inpatient unit and treatment. The relationship of CIWA-Ar scores and ethnicity was compared using analysis of variance. Results: A total of 115 whites, 45 Hispanics, and 47 Native Americans were included in the analysis. Native Americans had consistently lower CIWA-Ar scores at 0, 2, 4, and 6 hours than the other 2 ethnic groups (P = 0.002). In addition, Native Americans were admitted to the hospital less often than the other 2 groups for withdrawal (P < 0.001). Conclusions: The CIWA-Ar scale may underestimate the severity of alcohol withdrawal syndrome in certain ethnic group such as Native Americans. Further prospective studies should be undertaken to determine the validity of the CIWA-Ar scale in assessing alcohol withdrawal across different ethnic populations. Copyright © 2013 American Society of Addiction Medicine.
• Sanders, A. B., & Ewy, G. A. (2013). Alternative approach to improving survival of patients with out-of-hospital primary cardiac arrest.. Journal of the American College of Cardiology, 61(2), 113-8. doi:10.1016/j.jacc.2012.06.064
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  Out-of-hospital cardiac arrest (OHCA) is a common cause of death. In spite of recurring updates of guidelines, the survival of patients with OHCA was essentially unchanged from the mid 1970s to the mid 2000s, averaging 7.6% for all OHCA and 17.7% for OHCA due to ventricular fibrillation. In the past, changes in one's approach to resuscitation had to await the semi-decennial publications of guidelines. Following approved guidelines (at times based on consensus), survival rates of patients with OHCA were extremely variable, with only a few areas having good results. An alternative approach to improving survival is to use continuous quality improvement (CQI), a process often used to address public health problems. Continuous quality improvement advocates that one obtain baseline data and, if not optimal, make changes and continuously re-evaluate the results. Using CQI, we instituted cardiocerebral resuscitation as an alternative approach and found significant improvement in survival of patients with OHCA. The changes we made to the therapy of patients with primary OHCA, called cardiocerebral resuscitation, were based primarily on extensive experimental laboratory data. Using cardiocerebral resuscitation as a model for CQI, neurologically intact survival of patients with OHCA in ventricular fibrillation improved in 2 rural counties in Wisconsin, from 15% to 39%, and in 60 emergency medical systems in Arizona, to 38%. By advocating chest compression only CPR for bystanders of patients with primary OHCA and encouraging the use of cardiocerebral resuscitation by emergency medical systems, survival of patients with primary cardiac arrest in Arizona increased over a 5-year period from 17.7% to 33.7%. We recommend that all emergency medical systems determine their baseline survival rates of patients with OHCA and a shockable rhythm, and consider implementing the CQI approach if the community does not have a neurologically intact survival rate of at least 30%.
• Sanders, A. B., & Heidenreich, J. W. (2013). Response to Neset et al.. The Journal of emergency medicine, 44(5), 991-2. doi:10.1016/j.jemermed.2012.11.086
• Zuercher, M., Sanders, A. B., Otto, C. W., Kern, K. B., Hilwig, R. W., & Ewy, G. A. (2013). Abstract 278: Sodium Nitroprusside Combined With Epinephrine for Prolonged Ventricular Fibrillation Cardiac Arrest. Circulation, 128.
• Patanwala, A. E., Sanders, A. B., Weant, K. A., Erstad, B. L., Weant, K. A., Thomas, M. C., Sanders, A. B., Patanwala, A. E., Merritt, E. M., Erstad, B. L., Baker, S. N., & Acquisto, N. M. (2012). A prospective, multicenter study of pharmacist activities resulting in medication error interception in the emergency department.. Annals of emergency medicine, 59(5), 369-73. doi:10.1016/j.annemergmed.2011.11.013
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  The primary objective of this study is to determine the activities of pharmacists that lead to medication error interception in the emergency department (ED)..This was a prospective, multicenter cohort study conducted in 4 geographically diverse academic and community EDs in the United States. Each site had clinical pharmacy services. Pharmacists at each site recorded their medication error interceptions for 250 hours of cumulative time when present in the ED (1,000 hours total for all 4 sites). Items recorded included the activities of the pharmacist that led to medication error interception, type of orders, phase of medication use process, and type of error. Independent evaluators reviewed all medication errors. Descriptive analyses were performed for all variables..A total of 16,446 patients presented to the EDs during the study, resulting in 364 confirmed medication error interceptions by pharmacists. The pharmacists' activities that led to medication error interception were as follows: involvement in consultative activities (n=187; 51.4%), review of medication orders (n=127; 34.9%), and other (n=50; 13.7%). The types of orders resulting in medication error interceptions were written or computerized orders (n=198; 54.4%), verbal orders (n=119; 32.7%), and other (n=47; 12.9%). Most medication error interceptions occurred during the prescribing phase of the medication use process (n=300; 82.4%) and the most common type of error was wrong dose (n=161; 44.2%)..Pharmacists' review of written or computerized medication orders accounts for only a third of medication error interceptions. Most medication error interceptions occur during consultative activities.
• Sanders, A. B., & Ruttan, T. K. (2012). "Paramedics are bringing in a hypotensive gastrointestinal bleeder": an unexpected diagnosis.. The Journal of emergency medicine, 43(4), e227-9. doi:10.1016/j.jemermed.2010.02.031
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  Acute esophageal rupture is a rare emergency that must be diagnosed quickly and treated aggressively to avoid significant morbidity and mortality. The typical presentation of this disease includes chest pain, and the diagnosis is challenging when cardinal features such as this are absent..This case report discusses an atypical presentation of esophageal rupture in a patient with a predisposing condition and highlights the diagnostic and cognitive difficulties involved in making the appropriate diagnosis..We report a case of a 51-year-old woman who presented to the Emergency Department with hypotension and an emergency medical services report of hematemesis. The patient had a documented history of upper gastrointestinal bleeding and Zollinger-Ellison syndrome during her past hospitalizations; however, the patient was not anemic and had a negative stool guiac despite symptoms for 3 days. A subsequent chest radiograph led to the diagnosis of esophageal rupture with a bilateral pneumothorax requiring thoracostomies. She reported no chest pain..The esophageal rupture and subsequent hypotension was likely secondary to the combination of her Zollinger-Ellison syndrome and recent vomiting episodes. It is important to avoid premature diagnostic closure and think about unusual presentations of emergent conditions such as esophageal rupture.
• Sanders, A. B., Heidenreich, J. W., & Bonner, A. (2012). Rescuer fatigue in the elderly: standard vs. hands-only CPR.. The Journal of emergency medicine, 42(1), 88-92. doi:10.1016/j.jemermed.2010.05.019
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  Hands-only cardiopulmonary resuscitation (HO-CPR) is recommended as an alternative to standard CPR (STD-CPR). Studies have shown a degradation of adequate compressions with HO-CPR after 2 min when performed by young, healthy medical students. Elderly rescuers' ability to maintain an adequate compression rate and depth until emergency medical services (EMS) arrives is unknown..The specific aim of this study was to compare elderly rescuers' ability to maintain adequate compression rate and depth during HO-CPR and STD-CPR in a manikin model..In this prospective, randomized crossover study, 17 elderly volunteers performed both HO-CPR and STD-CPR, separated by at least 2 days, on a manikin model for 9 min each. The primary endpoint was the number of adequate chest compressions (> 38 mm) delivered per minute. Secondary endpoints were total compressions, compression rate, and the number of breaks taken for rest..There was no difference in the number of adequate compressions between groups in the first minute; however, the STD-CPR group delivered significantly more adequate chest compressions in minutes 2-9 (p
• Bobrow, B. J., Wendel, C. S., Sanders, A. B., Mosier, J., Mohler, M. J., Itty, A., Fain, M. J., Clark, L., & Bobrow, B. J. (2011). Cardiocerebral resuscitation improves out-of-hospital survival in older adults.. Journal of the American Geriatrics Society, 59(5), 822-6. doi:10.1111/j.1532-5415.2011.03400.x
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  To compare the survival and neurological status of people aged 65 and older receiving cardiocerebral resuscitation (CCR) with that of those receiving standard advanced life support (Std-ALS), as well as predictors of survival..Historical prospective cohort study..The Save Hearts in Arizona Registry (SHARE)..Persons who had experienced cardiac arrest receiving CCR or Std-ALS..Patient demographics, emergency medical service events, survival to hospital discharge, and out-of-hospital cardiac arrest (OHCA) outcomes were obtained from Arizona hospital records and Bureau of Public Health Statistics from 2005 to 2008..People receiving CCR were twice as likely to survive as those receiving Std-ALS (adjusted odds ratio=2.0, P=.005). An additional 20 per 1,000 older adults would survive, above the background survival rate of Std-ALS, if given CCR. More than 96% of those receiving CCR had good or moderate neurological outcomes, compared with 89% of those receiving Std.-ALS (P=.41)..CCR is associated with superior survival outcomes than Std-ALS for OHCAs in people aged 65 and older. Use of CCR in older adults without known do-not-resuscitate status is warranted. These findings should be understood within the broader context of the essential role of comprehensive advance care planning in providing care consistent with patient goals and values.
• Patanwala, A. E., Sanders, A. B., Weant, K. A., Erstad, B. L., Weant, K. A., Thomas, M. C., Sanders, A. B., Patanwala, A. E., Merritt, E., Erstad, B. L., Baker, S. N., & Acquisto, N. M. (2011). 219 A Prospective, Multicenter Study of Medication Errors Intercepted by Emergency Department Pharmacists. Annals of Emergency Medicine, 58(4), S251. doi:10.1016/j.annemergmed.2011.06.248
• Sanders, A. B. (2011). Cardiac arrest and the limitations of clinical trials.. The New England journal of medicine, 365(9), 850-1. doi:10.1056/nejme1108108
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  Out-of hospital cardiac arrest accounts for more than 330,000 deaths annually in the United States and Canada. Despite regular updates of guidelines for the management of these arrests, the rate of survival has been stagnant at 7.6% for more than 30 years.1,2 In this issue of the Journal, the Resuscitation Outcomes Consortium reports the results of two randomized comparisons3,4 from the Prehospital Resuscitation Impedance Valve and Early Versus Delayed Analysis (ROC PRIMED) trial (ClinicalTrials.gov number, NCT00394706), which evaluated potential improvements in the management of out-of hospital cardiac arrest. The first component of the ROC PRIMED trial compared two . . .
• Sanders, A. B., Kern, K. B., & Ewy, G. A. (2011). Compression-only cardiopulmonary resuscitation improves survival.. The American journal of medicine, 124(5), 383-5. doi:10.1016/j.amjmed.2010.09.024
• Sanders, A. B., Patanwala, A. E., Hays, D. P., & Erstad, B. L. (2011). Severity and probability of harm of medication errors intercepted by an emergency department pharmacist.. The International journal of pharmacy practice, 19(5), 358-62. doi:10.1111/j.2042-7174.2011.00122.x
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  OBJECTIVES The objective of this study was to evaluate the severity and probability of harm of medication errors (MEs) intercepted by an emergency department pharmacist. The phases of the medication-use process where MEs were most likely to be intercepted were determined. METHODS The emergency department was staffed with a full-time pharmacist during the 7-month study period. The MEs that were intercepted by the pharmacist were recorded in a database. Each ME in the database was independently scored for severity and probability of harm by two pharmacists and one physician investigator who were not involved in the data collection process. KEY FINDINGS There were 237 ME interceptions by the pharmacist during the study period. The final classification of MEs by severity was as follows: minor (n = 42; 18%), significant (n = 160; 67%) and serious (n = 35; 15%). The final classification of MEs by probability of harm was as follows: none (n = 13; 6%), very low (n = 96; 41%), low (n = 84; 35%), medium (n = 41; 17%) and high (n = 3; 1%). Inter-rater reliability for classification was as follows: error severity (agreement = 75.5%, kappa = 0.35) and probability of harm (agreement = 76.8%, kappa = 0.42). The MEs were most likely to be intercepted during the prescribing phase of the medication-use process (n = 236; 90.1%). CONCLUSIONS A high proportion of MEs intercepted by the emergency department pharmacist are considered to be significant or serious. However, a smaller percentage of these errors are likely to result in patient harm.
• Stolz, U., Bobrow, B. J., Welch, A., Vadeboncoeur, T. F., Stolz, U., Spaite, D. W., Sanders, A. B., Panchal, A. R., Kern, K. B., Ewy, G. A., Bobrow, B. J., & Berg, R. A. (2011). Abstract 64: Ability of Bystanders to Appropriately Provide Rescue Breathing in the Setting of a Chest Compression--Only CPR Campaign for Sudden Cardiac Arrest. Circulation, 124.
• Bobrow, B. J., Stolz, U., Vadeboncoeur, T. F., Stolz, U., Stapczynski, J. S., Spaite, D. W., Sanders, A. B., Mullins, T. J., Lovecchio, F., Kern, K. B., Humble, W. O., Gallagher, J. V., Ewy, G. A., Clark, L. L., Bobrow, B. J., & Berg, R. A. (2010). Chest compression-only CPR by lay rescuers and survival from out-of-hospital cardiac arrest.. JAMA, 304(13), 1447-54. doi:10.1001/jama.2010.1392
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  Chest compression-only bystander cardiopulmonary resuscitation (CPR) may be as effective as conventional CPR with rescue breathing for out-of-hospital cardiac arrest..To investigate the survival of patients with out-of-hospital cardiac arrest using compression-only CPR (COCPR) compared with conventional CPR..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..Survival to hospital discharge..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)..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.
• Bobrow, B. J., Vadeboncoeur, T. F., Spaite, D. W., Sanders, A. B., Roosa, J., Panchal, A. R., Kern, K. B., Geyer, B., & Bobrow, B. J. (2010). Abstract 44: Prevalence of Cardiac Catheterization and Outcomes From Out-of-Hospital Cardiac Arrest in a Consortium of Cardiac Receiving Centers. Circulation, 122.
• Bobrow, B. J., Wendel, C. S., Shellenberger, J., Sanders, A. B., Poulsen, J., Mosier, J., Mohler, J., Itty, A., Clark, L., & Bobrow, B. J. (2010). Cardiocerebral resuscitation is associated with improved survival and neurologic outcome from out-of-hospital cardiac arrest in elders.. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 17(3), 269-75. doi:10.1111/j.1553-2712.2010.00689.x
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  Recent studies have shown that a new emergency medical services (EMS) protocol for treating patients who suffer out-of-hospital cardiac arrest (OHCA), cardiocerebral resuscitation (CCR), significantly improves survival compared to standard advanced life support (ALS). However, due to their different physiology, it is unclear if all elders, or any subsets of elders who are OHCA victims, would benefit from the CCR protocol..The objectives of this analysis were to compare survival by age group for patients receiving CCR and ALS, to evaluate their neurologic outcome, and to determine what other factors affect survival in the subset of patients who do receive CCR..An analysis was performed of 3,515 OHCAs occurring between January 2005 and September 2008 in the Save Hearts in Arizona Registry. A total of 1,024 of these patients received CCR. Pediatric patients and arrests due to drowning, respiratory, or traumatic causes were excluded. The registry included data from 62 EMS agencies, some of which instituted CCR. Outcome measures included survival to hospital discharge and cerebral performance category (CPC) scores. Logistic regression evaluated outcomes in patients who received CCR versus standard ALS across age groups, adjusted for known potential confounders, including bystander cardiopulmonary resuscitation (CPR), witnessed arrest, EMS dispatch-to-arrival time, ventricular fibrillation (Vfib), and agonal respirations on EMS arrival. Predictors of survival evaluated included age, sex, location, bystander CPR, witnessed arrest, Vfib/ventricular tachycardia (Vtach), response time, and agonal breathing, based on bivariate results. Backward stepwise selection was used to confirm predictors of survival. These predictors were then analyzed with logistic regression by age category per 10 years of age..Individuals who received CCR had better outcomes across age groups. The increase in survival for the subgroup with a witnessed Vfib was most prominent on thoseor=80 years age group, which regained the benefit (1.8% vs. 4.6%, OR=2.56, 95% CI=1.10 to 5.97). Neurologic outcomes were also better in the patients who received CCR (OR=6.64, 95% CI=1.31 to 32.8). Within the subgroup that received CCR, the factors most predictive of improved survival included witnessed arrest, initial rhythm of Vfib/Vtach, agonal respirations upon arrival, EMS response time, and age. Neurologic outcome was not adversely affected by age..Cardiocerebral resuscitation is associated with better survival from OHCA in most age groups. The majority of patients in all age groups who survived to hospital discharge and who could be reached for follow-up had good neurologic outcome. Among patients receiving CCR for OHCA, witnessed arrest, Vfib/Vtach, agonal respirations, and early response time are significant predictors of survival, and these do not change significantly based on age.
• Bobrow, B. J., Zuercher, M., Sanders, A. B., Otto, C. W., Kern, K. B., Hilwig, R. W., Ewy, G. A., Clark, L., Chikani, V., Bobrow, B. J., & Berg, R. A. (2010). Gasping in response to basic resuscitation efforts: observation in a Swine model of cardiac arrest.. Critical care research and practice, 2010, 1485-1492. doi:10.1155/2010/351638
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  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.
• O'neil, B. J., Hiller, K. M., Fiorello, A. B., Sayre, M. R., Sanders, A. B., Peberdy, M. A., Paradis, N. A., O'neil, B. J., Larabee, T. M., Hiller, K. M., Heard, K. J., Geocadin, R. G., Fiorello, A. B., & Dixon, S. R. (2010). A randomized controlled trial comparing the Arctic Sun to standard cooling for induction of hypothermia after cardiac arrest.. Resuscitation, 81(1), 9-14. doi:10.1016/j.resuscitation.2009.09.015
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  Hypothermia improves neurological outcome for comatose survivors of out-of-hospital cardiac arrest. Use of computer controlled high surface area devices for cooling may lead to faster cooling rates and potentially improve patient outcome..To compare the effectiveness of surface cooling with the standard blankets and ice packs to the Arctic Sun, a mechanical device used for temperature management..Multi-center randomized trial of hemodynamically stable comatose survivors of out-of-hospital cardiac arrest..Standard post-resuscitative care inducing hypothermia using cooling blankets and ice (n=30) or the Arctic Sun (n=34)..The primary end point was the proportion of subjects who reached a target temperature within 4h of beginning cooling. The secondary end points were time interval to achieve target temperature (34 degrees C) and survival to 3 months..The proportion of subjects cooled below the 34 degrees C target at 4h was 71% for the Arctic Sun group and 50% for the standard cooling group (p=0.12). The median time to target was 54 min faster for cooled patients in the Arctic Sun group than the standard cooling group (p
• O'neil, B. J., Sayre, M. R., Sanders, A. B., Peberdy, M. A., Paradis, N. A., O'neil, B. J., Heard, K., & Geocadin, R. G. (2010). Abstract 63: Early Predictors of Good Neurologic Outcome From Out of Hospital Cardiac Arrest Treated With Therapeutic Hypothermia.. Circulation, 122.
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  Objective: To evaluate early predictors of neurological outcome in patients (pts) resuscitated from OOHCA from any initial rhythm treated with TH. Methods: This is a sub-analysis of a multi-center ...
• Sanders, A. B., & Ewy, G. A. (2010). Continuous chest compression CPR preferred for primary cardiac arrest.. Resuscitation, 81(6), 639-40. doi:10.1016/j.resuscitation.2010.04.001
• Stolz, U., Bobrow, B. J., Stolz, U., Spaite, D. W., Sanders, A. B., Panchal, A. R., Kern, K. B., Ewy, G. A., & Bobrow, B. J. (2010). Abstract 86: The Impact of Hands-OnlyTM CPR by Bystanders on Survival in Adult Victims of Out-of-Hospital Arrest Caused by Non-Cardiac Etiologies. Circulation, 122.
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  Introduction: The use of bystander CPR has demonstrated improved survival in patients with sudden, out of hospital cardiac arrest. Hands-Only™ (chest compression only) CPR is now endorsed by the AH...
• Stolz, U., Stolz, U., Spaite, D. W., Sanders, A. B., Panchal, A. R., Mullins, T., Kern, K. B., Geyer, B., Ewy, G. A., & Bobrow, B. (2010). Abstract 36: The Impact of a Statewide, Comprehensive System of Care on Survival From Out-of-Hospital Cardiac Arrest. Circulation, 122.
• Warholak, T. L., Sanders, A. B., Patanwala, A. E., & Erstad, B. L. (2010). A prospective observational study of medication errors in a tertiary care emergency department.. Annals of emergency medicine, 55(6), 522-6. doi:10.1016/j.annemergmed.2009.12.017
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  We determine the rate and severity of medication errors, as well as factors associated with error occurrence in the emergency department (ED)..This was a prospective observational study conducted between May 1, 2008, and February 1, 2009. The pharmacist observer was present in the ED for 28 shifts (12 hours each). Information was collected on the medication use process by observing the activities of nurses caring for the patients. Errors were categorized by severity. Logistic regression was used to analyze factors associated with a risk of medication error..The observer identified 178 medication errors in 192 patients during the data collection period. At least 1 error occurred in 59.4% of patients, and 37% of patients overall had an error that reached them. No errors in the study resulted in permanent harm to the patient or contributed to initial or prolonged hospitalization; however, interventions were performed to prevent patient harm that likely influenced the severity of error. Errors categorized according to stage were prescribing (53.9%), transcribing (10.7%), dispensing (0.6%), and administering (34.8%). Variables predictive of medication errors were boarded patient status (odds ratio [OR] 2.15; 95% confidence interval [CI] 1.03 to 4.5), number of medication orders (OR 1.25; 95% CI 1.12 to 1.39), number of medications administered (OR 1.22; 95% CI 1.07 to 1.38), and nursing employment status (less error if full time) (OR 0.37; 95% CI 0.16 to 0.86)..Medication errors in the ED are common, and most errors occur in the prescribing and administering phases. Boarded patient status, increasing number of medications orders, increasing number of medications administered, and part-time nursing status are associated with an increased risk of medication error.
• Yealy, D. M., Wright, K., Wilber, S. T., Wadhwani, K., Togias, A., Than, M., Tai, B., Sopko, G., Somers, S., Silverman, R., Shapiro, N. I., Shah, M. N., Scott, J. D., Sanders, A. B., Richardson, L. D., Peitzman, A. B., Nichol, G., Nathanson, L. A., Mutter, R., , Miers, S. E., et al. (2010). Summary of NIH Medical-Surgical Emergency Research Roundtable held on April 30 to May 1, 2009.. Annals of emergency medicine, 56(5), 522-37. doi:10.1016/j.annemergmed.2010.03.014
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  In 2003, the Institute of Medicine Committee on the Future of Emergency Care in the United States Health System convened and identified a crisis in emergency care in the United States, including a need to enhance the research base for emergency care. As a result, the National Institutes of Health (NIH) formed an NIH Task Force on Research in Emergency Medicine 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. The objectives of these discussions were to identify key research questions essential to advancing the scientific underpinnings of emergency care and to discuss the barriers and best means to advance research by exploring the role of research networks and collaboration between the NIH and the emergency care community..The Medical-Surgical Research Roundtable was convened on April 30 to May 1, 2009. Before the roundtable, the emergency care domains to be discussed were selected and experts in each of the fields were invited to participate in the roundtable. Domain experts were asked to identify research priorities and challenges and separate them into mechanistic, translational, and clinical categories. After the conference, the lists were circulated among the participants and revised to reach a consensus..Emergency care research is characterized by focus on the timing, sequence, and time sensitivity of disease processes and treatment effects. Rapidly identifying the phenotype and genotype of patients manifesting a specific disease process and the mechanistic reasons for heterogeneity in outcome are important challenges in emergency care research. Other research priorities include the need to elucidate the timing, sequence, and duration of causal molecular and cellular events involved in time-critical illnesses and injuries, and the development of treatments capable of halting or reversing them; the need for novel animal models; and the need to understand why there are regional differences in outcome for the same disease processes. Important barriers to emergency care research include a limited number of trained investigators and experienced mentors, limited research infrastructure and support, and regulatory hurdles. The science of emergency care may be advanced by facilitating the following: (1) training emergency care investigators with research training programs; (2) developing emergency care clinical research networks; (3) integrating emergency care research into Clinical and Translational Science Awards; (4) developing emergency care-specific initiatives within the existing structure of NIH institutes and centers; (5) involving emergency specialists in grant review and research advisory processes; (6) supporting learn-phase or small, clinical trials; and (7) performing research to address ethical and regulatory issues..Enhancing the research base supporting the care of medical and surgical emergencies will require progress in specific mechanistic, translational, and clinical domains; effective collaboration of academic investigators across traditional clinical and scientific boundaries; federal support of research in high-priority areas; and overcoming limitations in available infrastructure, research training, and access to patient populations.
• Zuercher, M., Sanders, A. B., Otto, C. W., Kern, K. B., Hilwig, R. W., Ewy, G. A., & Berg, R. A. (2010). Continued breathing followed by gasping or apnea in a swine model of ventricular fibrillation cardiac arrest.. BMC cardiovascular disorders, 10(1), 36. doi:10.1186/1471-2261-10-36
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  Continued breathing following ventricular fibrillation has here-to-fore not been described..We analyzed the spontaneous ventilatory activity during the first several minutes of ventricular fibrillation (VF) in our isoflurane anesthesized swine model of out-of-hospital cardiac arrest. The frequency and type of ventilatory activity was monitored by pneumotachometer and main stream infrared capnometer and analyzed in 61 swine during the first 3 to 6 minutes of untreated VF..During the first minute of VF, the air flow pattern in all 61 swine was similar to those recorded during regular spontaneous breathing during anesthesia and was clearly different from the patterns of gasping. The average rate of continued breathing during the first minute of untreated VF was 10 breaths per minute. During the second minute of untreated VF, spontaneous breathing activity either stopped or became typical of gasping. During minutes 2 to 5 of untreated VF, most animals exhibited very slow spontaneous ventilatory activity with a pattern typical of gasping; and the pattern of gasping was crescendo-decrescendo, as has been previously reported. In the absence of therapy, all ventilatory activity stopped 6 minutes after VF cardiac arrest..In our swine model of VF cardiac arrest, we documented that normal breathing continued for the first minute following cardiac arrest.
• Zuercher, M., Schuyler, T., Sattur, S., Sanders, A. B., Otto, C. W., Kern, K. B., Hilwig, R. W., & Ewy, G. A. (2010). Continuous chest compression resuscitation in arrested swine with upper airway inspiratory obstruction.. Resuscitation, 81(5), 585-90. doi:10.1016/j.resuscitation.2010.01.009
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  This study was designed to compare 24-h survival rates and neurological function of swine in cardiac arrest treated with one of three forms of simulated basic life support CPR..Thirty swine were randomized equally among three experimental groups to receive either 30:2 CPR with an unobstructed endotracheal tube (ET) or continuous chest compression (CCC) CPR with an unobstructed ET or CCC CPR with a collapsable rubber sleeve on the ET allowing air outflow but completely restricting air inflow. The swine were anesthetized but not paralyzed. Two min of untreated VF was followed by 9 min of simulated single rescuer bystander CPR. In the 30:2 CPR group, each set of 30 chest compressions was followed by a 15-s pause to simulate the realistic duration of interrupted chest compressions required for a single rescuer to deliver 2 mouth-to-mouth ventilations. The other two groups were provided continuous chest compressions (CCC) without assisted ventilations. At 11 min post-arrest a biphasic defibrillation shock (150 J) was administered followed by a period of advanced cardiac life support..In the 30:2 group, 8 of 10 animals had good neurological function at 24-h post-resuscitation. In the CCC open airway group, 10 of 10, and in the CCC inspiratory obstructed group, 9 of 10. The number of shocks (P
• Bobrow, B. J., Vadeboncoeur, T. F., Sanders, A. B., Kern, K. B., Hilwig, R. W., Ewy, G. A., Clark, L., Chikani, V., Bobrow, B. J., & Berg, R. A. (2009). Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest.. Annals of emergency medicine, 54(5), 656-662.e1. doi:10.1016/j.annemergmed.2009.06.011
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  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..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..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)..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.
• Bobrow, B. J., Vadeboncoeur, T. F., Striegel, T., Spaite, D. W., Sanders, A. B., Mullins, T., Kern, K. B., Geyer, B. C., Ewy, G. A., Clark, L., & Bobrow, B. J. (2009). Abstract P36: Statewide Network of Cardiac Arrest Centers Improves Survival From Out of Hospital Cardiac Arrest. Circulation, 120.
• Sanders, A. B. (2009). Elephants, quality, and doing the right thing.. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 16(5), 436-8. doi:10.1111/j.1553-2712.2009.00380.x
• Warholak-jackson, T., Sanders, A. B., Patanwala, A. E., & Erstad, B. L. (2009). 140: A Prospective Observational Study of Medication Errors in a Tertiary Care Academic Emergency Department. Annals of Emergency Medicine, 54(3), S44. doi:10.1016/j.annemergmed.2009.06.167
• Zuercher, M., Schuyler, T., Sattur, S., Sanders, A. B., Otto, C. W., Kern, K. B., Hilwig, R. W., & Ewy, G. A. (2009). Abstract 2538: Continuous Chest Compression Resuscitation in Arrested Swine With Upper Airway Inspiratory Obstruction. Circulation, 120.
• Bobrow, B. J., Sanders, A. B., Richman, P. B., Kern, K. B., Ewy, G. A., Clark, L. L., Chikani, V., Bobrow, B. J., & Berg, R. A. (2008). Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest.. JAMA, 299(10), 1158-65. doi:10.1001/jama.299.10.1158
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  Out-of-hospital cardiac arrest is a major public health problem..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..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..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..Survival-to-hospital discharge..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)..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.
• Bobrow, B. J., Vadeboncoeur, T. F., Spaite, D. W., Sanders, A. B., Kern, K. B., Ewy, G. A., Clark, L., Chikani, V., Bobrow, B. J., & Berg, R. A. (2008). Abstract P55: Survival From Out-of-Hospital Cardiac Arrest Among Patients Receiving AHA 2000 ACLS Guidelines, AHA 2005 ACLS Guidelines, or Cardiocerebral Resuscitation: A Statewide Analysis. Circulation, 118.
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  Objective: Survival of patients with out-of-hospital cardiac arrest (OHCA) receiving standard ACLS before and after the transition from AHA 2000 to 2005 guidelines in EMS systems across Arizona was...
• Bobrow, B. J., Zuercher, M., Sanders, A. B., Kern, K. B., Hilwig, R. W., Ewy, G. A., Donahue, D., Clark, L., Chikani, V., Bobrow, B. J., & Berg, R. A. (2008). Abstract P56: Gasping During Cardiac Arrest in Humans is Frequent, Associated with Improved Survival, and Needs Re-emphasis. Circulation, 118.
• Bobrow, B. J., Zuercher, M., Sanders, A. B., Kern, K. B., Hilwig, R. W., Ewy, G. A., Donahue, D., Clark, L., Chikani, V., Bobrow, B. J., & Berg, R. A. (2008). Gasping during cardiac arrest in humans is frequent and associated with improved survival.. Circulation, 118(24), 2550-4. doi:10.1161/circulationaha.108.799940
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  The incidence and significance of gasping after cardiac arrest in humans are controversial..Two approaches were used. The first was a retrospective analysis of consecutive confirmed out-of-hospital cardiac arrests from the Phoenix Fire Department Regional Dispatch Center text files to determine the presence of gasping soon after collapse. The second was a retrospective analysis of 1218 patients with out-of-hospital cardiac arrests in Arizona documented by emergency medical system (EMS) first-care reports to determine the incidence of gasping after arrest in relation to the various EMS arrival times. The primary outcome measure was survival to hospital discharge. An analysis of the Phoenix Fire Department Regional Dispatch Center records of witnessed and unwitnessed out-of-hospital cardiac arrests with attempted resuscitation found that 44 of 113 (39%) of all arrested patients had gasping. An analysis of 1218 EMS-attended, witnessed, out-of-hospital cardiac arrests demonstrated that the presence or absence of gasping correlated with EMS arrival time. Gasping was present in 39 of 119 patients (33%) who arrested after EMS arrival, in 73 of 363 (20%) when EMS arrival was 9 minutes. Survival to hospital discharge occurred in 54 of 191 patients (28%) who gasped and in 80 of 1027 (8%) who did not (adjusted odds ratio, 3.4; 95% confidence interval, 2.2 to 5.2). Among the 481 patients who received bystander cardiopulmonary resuscitation, survival to hospital discharge occurred among 30 of 77 patients who gasped (39%) versus only 38 of 404 among those who did not gasp (9%) (adjusted odds ratio, 5.1; 95% confidence interval, 2.7 to 9.4)..Gasping or abnormal breathing is common after cardiac arrest but decreases rapidly with time. Gasping is associated with increased survival. These results suggest that the recognition and importance of gasping should be taught to bystanders and emergency medical dispatchers so as not to dissuade them from initiating prompt resuscitation efforts when appropriate.
• Sanders, A. B. (2008). Progress in improving neurologically intact survival from cardiac arrest.. Annals of emergency medicine, 52(3), 253-5. doi:10.1016/j.annemergmed.2008.04.018
• Sanders, A. B., & Kern, K. B. (2008). Surviving cardiac arrest: location, location, location.. JAMA, 300(12), 1462-3. doi:10.1001/jama.300.12.1462
• Vadeboncoeur, T. F., Spaite, D. W., Sanders, A. B., Mullins, T., Clark, L., Chikani, V., & Bobrow, B. J. (2008). The impact of prehospital transport interval on survival in out-of-hospital cardiac arrest: implications for regionalization of post-resuscitation care.. Resuscitation, 79(1), 61-6. doi:10.1016/j.resuscitation.2008.05.006
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  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..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..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)..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.
• Zuercher, M., Sanders, A. B., Otto, C. W., Kern, K. B., Hilwig, R. W., Hayes, M. M., Ewy, G. A., & Berg, R. A. (2008). Response to Letter Regarding Article “Improved Neurological Outcome With Continuous Chest Compressions Compared With 30:2 Compressions-to-Ventilations Cardiopulmonary Resuscitation in a Realistic Swine Model of Out-of-Hospital Cardiac Arrest”. Circulation, 117(24). doi:10.1161/circulationaha.108.772202
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  We are pleased to be able to respond to the concerns about chest compressions without ventilations for victims of out-of-hospital cardiac arrest expressed by Rottenberg and the relevance of our swine model to patients. Similar concerns by others are in part the reason why continuous-chest-compression cardiopulmonary resuscitation (CCC CPR) has not as yet been included in Guidelines. As Rottenberg noted, in humans, the tongue, soft palate, and/or the epiglottis may act as a 1-way valve. This may result in partial obstruction, but it does not prevent the gasping effort. In fact, this …
• Bobrow, B. J., Sanders, A. B., Richman, P. B., Kern, K. B., Ewy, G. A., Clark, L., Bobrow, B. J., & Berg, R. A. (2007). Cardiocerebral Resuscitation Improves Survival from Out-of-hospital Cardiac Arrest. Academic Emergency Medicine, 14(5 Supplement 1), S11-S11. doi:10.1197/j.aem.2007.03.715
• Bobrow, B. J., Sanders, A. B., Richman, P. B., Noelck, N., Clark, L., & Bobrow, B. J. (2007). Ability of citizens in a senior living community to perform lifesaving cardiac skills and appropriately utilize AEDs.. The Journal of emergency medicine, 33(4), 395-9. doi:10.1016/j.jemermed.2007.02.020
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  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.
• Bobrow, B. J., Vadeboncoeur, T. F., Sanders, A. B., Kern, K. B., Ewy, G. A., Clark, L., Bobrow, B. J., & Berg, R. A. (2007). The Save Hearts in Arizona Registry and Education (SHARE) program: who is performing CPR and where are they doing it?. Resuscitation, 75(1), 68-75. doi:10.1016/j.resuscitation.2007.02.015
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  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..To determine true incidence and location of layperson CPR in the State of Arizona..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..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..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.
• Bobrow, B. J., Vadeboncoeur, T. F., Shimmin, S., Sanders, A. B., Richman, P. B., Kern, K. B., Clark, L., & Bobrow, B. J. (2007). 197: Witnessed Arrest With Bystander-Initiated Cardiopulmonary Resuscitation Increases the Incidence of Ventricular Fibrillation Found by First Responders. Annals of Emergency Medicine, 50(3), S62-S63. doi:10.1016/j.annemergmed.2007.06.349
• Sanders, A. B. (2007). Mental status assessment in emergency medicine.. Internal and emergency medicine, 2(2), 116-8. doi:10.1007/s11739-007-0032-z
• Sanders, A. B., Otto, C. W., Kern, K. B., Hilwig, R. W., Hayes, M. M., Ewy, G. A., Berg, R. A., & Anavy, N. D. (2007). Continuous passive oxygen insufflation results in a similar outcome to positive pressure ventilation in a swine model of out-of-hospital ventricular fibrillation.. Resuscitation, 74(2), 357-65. doi:10.1016/j.resuscitation.2007.01.004
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  The deleterious effects of positive pressure ventilation may be prevented by substituting passive oxygen insufflation during advanced cardiac life support (ACLS) cardiopulmonary resuscitation (CPR)..We compared 24-h neurologically normal survival among three different ventilation scenarios for ACLS in a realistic swine model of out-of-hospital prolonged ventricular fibrillation (VF) cardiac arrest. No bystander CPR was provided during the first 8 min of untreated VF before the simulated arrival of an emergency medical system (EMS). Thirty-six swine were randomly assigned to one of three experimental groups. Group I (standard ventilation) was mechanically ventilated at 10 respirations per minute (RPM) at a tidal volume (TV) of 10 ml/kg with 100% oxygen. Group II (hyperventilation) was ventilated at 35 RPM at a TV of 20 ml/kg with 100% oxygen. In Group III (insufflation) animals, a nasal cannula was placed in the oropharynx to administer oxygen continuously at 10 l/min..There was no significant difference in the 24h neurologically normal survival among groups (standard: 2/12, hyperventilation: 2/12, insufflation: 4/12; p=.53)..Passive insufflation may be an acceptable alternative to the currently recommended positive pressure ventilation during resuscitation efforts for out-of-hospital VF cardiac arrest. Potential advantages of this technique include: (1) easier to teach, (2) easier to administer, (3) prevention of the adverse effects of positive pressure ventilation and (4) allows EMS personnel to concentrate upon other critically important duties.
• Wears, R. L., Swing, S. R., Spillane, L., Smith-coggins, R., Schneider, S. M., Sanders, A. B., Radford, M. J., Lukens, T. W., Hruska, L., Hobgood, C., Graff, L. G., Chapman, D. M., & Bizovi, K. (2007). Using patient care quality measures to assess educational outcomes.. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 14(5), 463-73. doi:10.1197/j.aem.2006.12.011
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  To report the results of a project designed to develop and implement a prototype methodology for identifying candidate patient care quality measures for potential use in assessing the outcomes and effectiveness of graduate medical education in emergency medicine..A workgroup composed of experts in emergency medicine residency education and patient care quality measurement was convened. Workgroup members performed a modified Delphi process that included iterative review of potential measures; individual expert rating of the measures on four dimensions, including measures quality of care and educational effectiveness; development of consensus on measures to be retained; external stakeholder rating of measures followed by a final workgroup review; and a post hoc stratification of measures. The workgroup completed a structured exercise to examine the linkage of patient care process and outcome measures to educational effectiveness..The workgroup selected 62 measures for inclusion in its final set, including 43 measures for 21 clinical conditions, eight medication measures, seven measures for procedures, and four measures for department efficiency. Twenty-six measures met the more stringent criteria applied post hoc to further stratify and prioritize measures for development. Nineteen of these measures received high ratings from 75% of the workgroup and external stakeholder raters on importance for care in the ED, measures quality of care, and measures educational effectiveness; the majority of the raters considered these indicators feasible to measure. The workgroup utilized a simple framework for exploring the relationship of residency program educational activities, competencies from the six Accreditation Council for Graduate Medical Education general competency domains, patient care quality measures, and external factors that could intervene to affect care quality..Numerous patient care quality measures have potential for use in assessing the educational effectiveness and performance of graduate medical education programs in emergency medicine. The measures identified in this report can be used as a starter set for further development, implementation, and study. Implementation of the measures, especially for high-stakes use, will require resolution of significant measurement issues.
• Zuercher, M., Sanders, A. B., Otto, C. W., Kern, K. B., Hilwig, R. W., Hayes, M. M., Ewy, G. A., & Berg, R. A. (2007). Improved neurological outcome with continuous chest compressions compared with 30:2 compressions-to-ventilations cardiopulmonary resuscitation in a realistic swine model of out-of-hospital cardiac arrest.. Circulation, 116(22), 2525-30. doi:10.1161/circulationaha.107.711820
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  The 2005 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care changed the previous ventilations-to-chest-compression algorithm for bystander cardiopulmonary resuscitation (CPR) from 2 ventilations before each 15 chest compressions (2:15 CPR) to 30 chest compressions before 2 ventilations (30:2 CPR). It was acknowledged in the guidelines that the change was based on a consensus rather than clear evidence. This study was designed to compare 24-hour neurologically normal survival between the initial applications of continuous chest compressions without assisted ventilations with 30:2 CPR in a swine model of witnessed out-of-hospital ventricular fibrillation cardiac arrest..Sixty-four animals underwent 12 minutes of ventricular fibrillation before defibrillation attempts. They were divided into 4 groups, each with increasing durations (3, 4, 5, and 6 minutes, respectively) of untreated ventricular fibrillation before the initiation of bystander resuscitation consisting of either continuous chest compression or 30:2 CPR. After the various untreated ventricular durations plus bystander resuscitation durations, all animals were given the first defibrillation attempt 12 minutes after the induction of ventricular fibrillation, followed by the 2005 guideline-recommended advanced cardiac life support. Neurologically normal survival at 24 hours after resuscitation was observed in 23 of 33 (70%) of the animals in the continuous chest compression groups but in only 13 of 31 (42%) of the 30:2 CPR groups (P=0.025)..In a realistic model of out-of-hospital ventricular fibrillation cardiac arrest, initial bystander administration of continuous chest compressions without assisted ventilations resulted in significantly better 24-hour postresuscitation neurologically normal survival than did the initial bystander administration of 2005 guideline-recommended 30:2 CPR.
• Bobrow, B. J., Vadeboncoeur, T. F., Sanders, A. B., Kern, K. B., Ewy, G. A., Clark, L., Bobrow, B. J., & Berg, R. A. (2006). Abstract 3: The Save Hearts in Arizona Registry and Education (SHARE) Program: Who is Performing Cardiopulmonary Resuscitation and Where are They Doing It?. Circulation, 114.
• Sanders, A. B. (2006). Therapeutic hypothermia after cardiac arrest.. Current opinion in critical care, 12(3), 213-7. doi:10.1097/01.ccx.0000224864.93829.d4
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  Patients who are successfully resuscitated following cardiac arrest often have a significant medical condition termed postresuscitation disease. This includes myocardial stunning, metabolic abnormalities and neurologic injury from global ischemia. There are no clinical signs or diagnostic tests for 24-72 h to distinguish patients who will and will not recover neurologic function..Therapeutic hypothermia had been advocated for decades as a treatment to improve neurologic outcome after cardiac arrest. The early studies focused on moderate hypothermia, which was associated with complications and was not clearly beneficial. Over the past decade, studies have focused on mild hypothermia with target temperatures of 32-34 degrees C. Two recent multicentered, randomized, controlled trials have demonstrated improved neurologic outcome with mild therapeutic hypothermia applied to comatose survivors after cardiac arrest compared with a normothermic control group..As a result of these studies the International Liaison Committee on Resuscitation recommends that 'Unconscious adult patients with spontaneous circulation after out-of-hospital cardiac arrest should be cooled to 32 degrees C to 34 degrees C for 12 to 24 hours when the initial rhythm was ventricular fibrillation'. Mild therapeutic hypothermia should also be considered for patients with in-hospital arrest and asystole and pulseless electrical activity who are comatose after return of spontaneous circulation.
• Sanders, A. B., Kern, K. B., Higdon, T. A., Heidenreich, J. W., Ewy, G. A., & Berg, R. A. (2006). Rescuer fatigue: standard versus continuous chest-compression cardiopulmonary resuscitation.. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 13(10), 1020-6. doi:10.1197/j.aem.2006.06.049
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  Continuous chest-compression cardiopulmonary resuscitation (CCC-CPR) has been advocated as an alternative to standard CPR (STD-CPR). Studies have shown that CCC-CPR delivers substantially more chest compressions per minute and is easier to remember and perform than STD-CPR. One concern regarding CCC-CPR is that the rescuer may fatigue and be unable to maintain adequate compression rate or depth throughout an average emergency medical services response time. The specific aim of this study was to compare the effects of fatigue on the performance of CCC-CPR and STD-CPR on a manikin model..This was a prospective, randomized crossover study involving 53 medical students performing CCC-CPR and STD-CPR on a manikin model. Students were randomized to their initial CPR group and then performed the other type of CPR after a period of at least two days. Students were evaluated on their performance of 9 minutes of CPR for each method. The primary endpoint was the number of adequate chest compressions (at least 38 mm of compression depth) delivered per minute during each of the 9 minutes. The secondary endpoints were total compressions, compression rate, and the number of breaks taken for rest. The students' performance was evaluated on the basis of Skillreporter Resusci Anne (Laerdal, Wappingers Falls, NY) recordings. Primary and secondary endpoints were analyzed by using the generalized linear mixed model for counting data..In the first 2 minutes, participants delivered significantly more adequate compressions per minute with CCC-CPR than STD-CPR, (47 vs. 32, p = 0.004 in the 1st minute and 39 vs. 29, p = 0.04 in the 2nd minute). For minutes 3 through 9, the differences in number of adequate compressions between groups were not significant. Evaluating the 9 minutes of CPR as a whole, there were significantly more adequate compressions in CCC-CPR vs. STD-CPR (p = 0.0003). Although the number of adequate compressions per minute declined over time in both groups, the rate of decline was significantly greater in CCC-CPR compared with STD-CPR (p = 0.0003). The mean number of total compressions delivered in the first minute was significantly greater with CCC-CPR than STD-CPR (105 per minute vs. 58 per minute, p < 0.001) and did not change over 9 minutes in either group. There were no differences in compression rates or number of breaks between groups..CCC-CPR resulted in more adequate compressions per minute than STD-CPR for the first 2 minutes of CPR. However, the difference diminished after 3 minutes, presumably as a result of greater rescuer fatigue with CCC-CPR. Overall, CCC-CPR resulted in more total compressions per minute than STD-CPR during the entire 9 minutes of resuscitation.
• Sanders, A. B., Kern, K. B., Hilwig, R. W., Higdon, T. A., Heidenreich, J. W., Ewy, G. A., Clark, L. L., & Berg, R. A. (2006). Single rescuer cardiopulmonary resuscitation: can anyone perform to the guidelines 2000 recommendations?. Resuscitation, 71(1), 34-9. doi:10.1016/j.resuscitation.2006.02.020
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  The Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care recommend that for adult cardiac arrest the single rescuer performs "two quick breaths followed by 15 chest compressions." This cycle is continued until additional help arrives. Previous studies have shown that lay persons and medical students take 16 +/- 1 and 14 +/- 1 s, respectively, to perform these "two quick breaths." The purpose of this study was to determine the time required for trained professional paramedic firefighters to deliver these two breaths and the effects that any increase in the time it takes to perform rescue breathing would have on the number of chest compressions delivered during single rescuer BLS CPR. We hypothesized that trained professional rescuers would also take substantially longer then the Guidelines recommendation for delivering the two rescue breaths before every 15 compressions during simulated single rescuer BLS CPR..Twenty-four paramedic firefighters currently certified to perform BLS CPR were evaluated for their ability to deliver the two recommended breaths within 4 s according to the AHA 2000 CPR Guidelines. Alternatively, a simplified technique of continuous chest compression BLS CPR (CCC) was also taught and compared with standard BLS CPR (STD). Without revealing the purpose of the study the paramedics were asked to perform single rescuer BLS CPR on a recording Resusci Anne while being videotaped..The mean length of time needed to provide the "two quick breaths" during STD-CPR was 10 +/- 1 s. The mean number of chest compressions/min delivered with AHA BLS CPR was only 44 +/- 2. Continuous chest compression CPR resulted in 88 +/- 5 compressions delivered per minute (STD versus CCC; p < 0.0001)..Trained professional emergency rescue workers perform rescue breathing somewhat faster than lay rescuers or medical students, but still require two and one half times longer than recommended. The time required to perform these breaths significantly decreases the number of chest compressions delivered per minute. This may affect outcome as experimental studies have shown that more than 80 compressions delivered per minute are necessary for survival from prolonged cardiac arrest.
• Sanders, A. B., Otto, C. W., Kern, K. B., Hilwig, R. W., Hayes, M. M., Ewy, G. A., & Berg, R. A. (2006). Abstract 2663: The Importance of Gasping During Ventricular Fibrillation Cardiac Arrest for 24-hr Neurologically Normal Survival. Circulation, 114.
• Sanders, A. B., Otto, C. W., Kern, K. B., Hilwig, R. W., Hayes, M. M., Ewy, G. A., & Berg, R. A. (2006). Abstract 89: Optimal Bystander CPR: 30:2 versus Continuous Chest Compressions?. Circulation, 114.
• Sanders, A. B., Otto, C. W., Kern, K. B., Hilwig, R. W., Hayes, M. M., Ewy, G. A., Berg, R. A., & Anavy, N. D. (2006). Abstract 46: Alternative Approaches to Ventilation by Emergency Medical Services after Prolonged Untreated Ventricular Fibrillation Cardiac Arrest: A Porcine Model Study. Circulation, 114.
• Sayre, M. R., Sanders, A. B., Kern, K. B., Ewy, G. A., Clark, L., Bobrow, B., & Berg, R. A. (2006). Abstract 1774: Establishing a Statewide Cardiac Arrest Reporting and Educational Network: The Arizona Experience. Circulation, 114.
• Valenzuela, T. D., Sanders, A. B., Otto, C. W., Newburn, D., Martinez, P., Kern, K. B., Hilwig, R. W., Hayes, M. M., Ewy, G. A., Clark, L., & Berg, R. A. (2006). Cardiocerebral resuscitation for cardiac arrest.. The American journal of medicine, 119(1), 6-9. doi:10.1016/j.amjmed.2005.06.067
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  Survival rates from out-of-hospital cardiac arrest continue to be low despite periodic updates in the Guidelines for Emergency Medical Services and periodic improvements such as the addition of automatic external defibrillators (AEDs). The low incidence of bystander cardiopulmonary resuscitation (CPR), substantial time without chest compressions throughout the resuscitation effort, and a lack of response to initial defibrillation after prolonged ventricular fibrillation contribute to these unacceptably poor results. Resuscitation guidelines are only revised every 5 to 7 years and can be difficult to change because of the lack of randomized controlled trials in humans. Such trials are rare because of a number of logistical difficulties, including the problem of obtaining informed consent. An alternative approach to advancing resuscitation science is for evidence-based demonstration projects in areas that have adequate records, so that one may determine whether the new approach improves survival. This is reasonable because the current guidelines make provisions for deviations under certain local circumstances or as directed by the emergency medical services medical director. A wealth of experimental evidence indicates that interruption of chest compressions for any reason in patients with cardiac arrest is deleterious. Accordingly, a new approach to out-of-hospital cardiac arrest called cardiocerebral resuscitation (CCR) was developed that places more emphasis on chest compressions for witnessed cardiac arrest in adults and de-emphasizes ventilation. There is also emphasis on chest compressions before defibrillation in circulatory phase of cardiac arrest. CCR was initiated in Tucson, Arizona, in November 2003, and in two rural Wisconsin counties in early 2004.
• Hiller, K. M., Sanders, A. B., Hiller, K. M., & Duldner, J. (2005). Researchers' understanding of the federal guidelines for waiver of and exception from informed consent.. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 12(11), 1045-9. doi:10.1197/j.aem.2005.06.013
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  The survival of patients who present to the emergency department with severe injury or illness is dismal. Resuscitation researchers are interested in advancing the science of resuscitation, and clinical studies must be conducted to determine the best treatment protocols. These studies must reflect good science and must balance individual patient autonomy and safety with scientific progress that benefits society as a whole. Researchers find the present federal guidelines on waiver of and exception from informed consent to be time consuming and expensive. They see variability in the requirements as interpreted by institutional review boards. There is confusion regarding the requirements for public notification and response to community consultation. They believe that the majority of the public, as well as health care professionals, want resuscitation research to progress, but a minority of people and governmental regulators are uncomfortable with waiver of and exception from informed consent for research studies. There is concern and some evidence that the federal guidelines have impeded the advancement of resuscitation science. Several strategies have been suggested to improve the situation. These include 1) better education of resuscitation researchers regarding the federal guidelines, 2) a toolbox for resuscitation researchers clarifying the guidelines, 3) advocacy for the advancement of resuscitation science as a public good, and 4) a national research advisory board that provides unbiased reviews of clinical studies and guidelines for local institutional review boards regarding risks, benefits, and communication strategies for waiver of and exception from consent proposals.
• Sanders, A. B., & Ewy, G. A. (2005). Cardiopulmonary resuscitation in the real world: when will the guidelines get the message?. JAMA, 293(3), 363-5. doi:10.1001/jama.293.3.363
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  THE GUIDELINES FOR CARDIOPULMONARY RESUSCITAtion (CPR) and Emergency Cardiovascular Care (ECC) are probably the most widely implemented and best-known guidelines in medicine. In the setting of cardiac arrest, health care professionals want and need simple, practical, and effective guidelines. As the American Heart Association (AHA) and International Liaison Committee on Resuscitation (ILCOR) revise their Consensus on Science and Treatment Guidelines in 2005, it is imperative to assess how these guidelines are developed. Despite the major reassessment and publication of new CPR and ECC guidelines every 5 to 8 years for the past 3 decades, survival from cardiac arrest remains dismal. Have the guidelines and guideline development process improved or compromised the treatment of patients in cardiac arrest? Do they reflect the reality of cardiac arrest treatment? Are they responsive, or impenetrable, to new ideas and concepts in ECC? Are there ways to improve the guidelines process and, therefore, the guidelines themselves? The studies by Wik et al and Abella et al in this issue of JAMA document a major problem in the treatment of patients in cardiac arrest. Using a sternal pad to monitor chest compressions and ventilations, Wik et al obtained data from paramedics and nurse anesthetists performing CPR on 176 adult patients with out-of-hospital cardiac arrest in 3 cities in Europe. They found that chest compressions were not provided 48% of the time with patients in cardiac arrest. Despite using a compression rate of 121/min, these rescue personnel, with the documented interruptions, delivered only 64 chest compressions per minute. Abella et al, using the same monitoring device to observe 67 in-hospital cardiac arrests, found that patients did not receive chest compressions 24% of the time during the resuscitation. Other problems identified in the CPR segments analyzed included ventilations of 20/min or more (61%), compression rates less than 90/min (28%), and inadequate compression depth (37%). Although neither of these studies was powered to assess patient survival, Abella et al found a trend showing that patients who had longer periods without chest compression had worse resuscitation outcome. These reports are consistent with previous studies documenting low chest compression rates and high ventilation rates when CPR is performed by health care professionals. They also complement studies looking at how laypersons and health professionals deliver CPR in cardiac arrest simulations. Assar et al demonstrated that laypersons taught single-rescuer CPR take an average of 16 seconds for each ventilatory pause. A recent study from our CPR Research Group showed that medical students needed 14 seconds to deliver 2 breaths during CPR and delivered only 43 chest compressions per minute after AHA standard CPR training because of pauses for ventilations. Students taught a simplified chest-compression-only CPR delivered 113 compressions per minute immediately after training and 91 compressions per minute when tested 6 months later. Thus, laypersons, medics, physicians, nurses, medical students, and other health care professionals do not perform CPR according to published guidelines. However, this conclusion is not surprising. Indeed, studies demonstrating poor retention of CPR skills have documented the poor performance of CPR for more than 3 decades. Does the quality of CPR make a difference in patient outcomes? Although there are no randomized controlled trials (RCTs) to answer this question, observational studies in both experimental models and humans indicate that the quality of CPR is likely to affect patient outcome. Kern et al demonstrated that when animals received realistic 16-second pauses for ventilations, 24-hour neurologically intact survival was 13% compared with 80% in the group receiving continuous chest compressions. Yu et al showed that 100% of animals receiving more than 80 compressions per minute were resuscitated whereas only 10% of those receiving fewer than 80 compressions per minute survived.
• Sanders, A. B., & Ewy, G. A. (2005). Guidelines for Cardiopulmonary Resuscitation—Reply. JAMA, 293(22), 2713-2714. doi:10.1001/jama.293.22.2713-b
• Sanders, A. B., Nolan, J. P., Nadkarni, V., Montgomery, W. H., Ewy, G. A., & Billi, J. E. (2005). Guidelines for cardiopulmonary resuscitation (multiple letters). JAMA, 293(22), 2713-2714.
• Sanders, A. B., Kern, K. B., Higdon, T. A., Heidenreich, J. W., & Ewy, G. A. (2004). 34 UNINTERRUPTED CHEST COMPRESSION VERSUS STANDARD CARDIOPULMONARY RESUSCITATION IN MEDICAL STUDENTS: IMPROVED COMPRESSION PERFORMANCE. Journal of Investigative Medicine, 52(Suppl 1), S84.4-S84. doi:10.1136/jim-52-suppl1-34
• Sanders, A. B., Kern, K. B., Higdon, T. A., Heidenreich, J. W., Ewy, G. A., & Berg, R. A. (2004). Uninterrupted chest compression CPR is easier to perform and remember than standard CPR.. Resuscitation, 63(2), 123-30. doi:10.1016/j.resuscitation.2004.04.011
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  It has long been observed that CPR skills rapidly decline regardless of the modality used for teaching or criteria used for testing. Uninterrupted chest compression CPR (UCC-CPR) is a proposed alternative to standard single rescuer CPR (STD-CPR) for laypersons in witnessed unexpected cardiac arrest in adults. It delivers substantially more compressions per minute and may be easier to remember and perform than standard CPR..In this prospective study, 28 medical students were taught STD-CPR and UCC-CPR and then were tested on each method at baseline (0), 6, and 18 months after training. The students' performance for at least 90 s of CPR was evaluated based on video and Laerdal Skillreporter Resusci Anne recordings..The mean number of correct chest compressions delivered per minute trended down over time in STD-CPR (23 +/- 3, 19 +/- 4 , and 15 +/- 3; P = 0.09) but stayed the same in UCC-CPR (43 +/- 9, 38 +/- 7, and 37 +/- 7 = 0.91) at 0, 6, and 18 months, respectively. The mean percentage of chest compressions delivered correctly fell over time in STD-CPR (54 +/- 6%, 35 +/- 6%, and 32 +/- 6%; P = 0.02) but stayed the same in UCC-CPR (34 +/- 5%, 41 +/- 7%, and 38 +/- 8%) at 0, 6, and 18 months, respectively. The number of chest compressions delivered per minute was higher in UCC-CPR at 0, 6, and 18 months (113 versus 44, P < 0.0001; 94 versus 47, P < 0.0001; and 92 versus 44, P < 0.001). The greater number of chest compressions was due to a mean ventilaroty pause of 13-14 s during STD-CPR at all three time points..Chest compression performance during STD-CPR declined in repeated testing over 18 months whereas there was minimal decline in chest compressions performance on repeated testing of UCC-CPR. In addition, substantially more chest compressions were delivered during UCC-CPR compared to STD-CPR at all time points primarily because of long pauses accompanying rescue breathing.
• Sanders, A. B., Kern, K. B., Hilwig, R. W., Higdon, T. A., Heidenreich, J. H., Ewy, G. A., Berg, R. A., & Anavy, N. D. (2004). Effect of vasopressin on postresuscitation ventricular function: unknown consequences of the recent Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.. Critical care medicine, 32(9 Suppl), S393-7. doi:10.1097/01.ccm.0000139459.39372.71
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  To compare the effect on postresuscitation left ventricular function of vasopressin vs. epinephrine used during cardiopulmonary resuscitation in a swine model of prolonged prehospital ventricular fibrillation..Prospective, randomized experimental study..University large animal resuscitation research laboratory..Forty-eight swine (29 +/- 1 kg)..Resuscitation after 12.5 mins of untreated ventricular fibrillation, randomizing animals during cardiopulmonary resuscitation to treatment with epinephrine, vasopressin, or vasopressin followed by a vasopressin antagonist administered in the postresuscitation period..Serial measurements of left ventricular systolic and diastolic function (prearrest, postresuscitation at 30 mins and 6 hrs) and 24-hr survival. Animals receiving vasopressin had more postresuscitation left ventricular dysfunction than those receiving epinephrine (p < .05). The vasopressin antagonist produced vasodilation and improved early postresuscitation left ventricular systolic and diastolic function but did not have a lasting effect on such postresuscitation ventricular function and decreased 24-hr survival compared with the use of vasopressin alone (3/16 vs. 10/16 survivors; p < .05)..Vasopressin use during cardiopulmonary resuscitation results in worse postresuscitation left ventricular function early but did not compromise 24-hr outcome. Reversal of vasopressin's effect with a specific V-1 antagonist in the postresuscitation period did not improve survival.
• Sanders, A. B., Niebler, R. A., Kern, K. B., Higdon, T. A., Hendrickson, J., Heidenreich, J. W., Ewy, G. A., & Berg, R. A. (2004). Single-rescuer cardiopulmonary resuscitation: 'two quick breaths'--an oxymoron.. Resuscitation, 62(3), 283-9. doi:10.1016/j.resuscitation.2004.05.013
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  The Guidelines 2000 for CPR and ECC recommend for single lay-rescuers performing basic life support, "two quick breaths followed by 15 chest compressions", repeated until professional help arrives. It is uncertain that this can actually be accomplished by the majority of lay rescuers. We evaluated 53 first-year medical students after completing BLS CPR training to determine if they could deliver the goal of 80 compressions per minute when following this AHA BLS recommendation. Alternatively, a simplified technique of uninterrupted chest compression (UCC) BLS CPR was also taught and compared with standard BLS CPR (STD). The mean number of chest compressions/minute delivered with AHA BLS CPR was only 43 +/- 1 immediately after initial training and 49 +/- 2 when tested 6 months later. Uninterrupted chest compression BLS resulted in 113 +/- 2 compressions/min delivered immediately after training and 91 +/- 4 six months later (STD versus UCC; P < 0.0001). The mean length of time needed to provide the two breaths during STD-CPR was 14 +/- 1 and 12 +/- 1s (immediately after first training and six months after training). For STD-CPR, the mean minute ventilation was poor immediately after initial training (3.3 +/- 0.3 l/min) and further declined (1.9 +/- 0.4 l/min) at 6 months (P = 0.003). For single rescuer basic cardiopulmonary resuscitation, motivated BLS CPR-trained medical students take nearly as long as previously reported for middle-aged lay individuals to deliver these "two quick breaths". The "Guidelines 2000" recommendation for "two quick breaths" is an oxymoron, as it averages more than 13s. New recommendations for single-rescuer CPR should be considered that emphasize uninterrupted chest compressions.
• Swing, S. R., Sulton, L., Smith-coggins, R., Sanders, A. B., Perina, D. G., Laduca, T., Hayden, S. R., Dyne, P. L., Corrigan, K., Chinnis, A., Chapman, D. M., & Binder, L. S. (2004). Integrating the Accreditation Council for Graduate Medical Education Core Competencies into the Model of the Clinical Practice of Emergency Medicine. Academic Emergency Medicine, 11(6), 674-685. doi:10.1197/j.aem.2004.02.008
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  In response to public pressure for greater accountability from the medical profession, a transformation is occurring in the approach to medical education and assessment of physician competency. Over the past 5 years, the Accreditation Council for Graduate Medical Education (ACGME) has implemented the Outcomes and General Competencies projects to better ensure that physicians are appropriately trained in the knowledge and skills of their specialties. Concurrently, the American Board of Medical Specialties, including the American Board of Emergency Medicine (ABEM), has embraced the competency concept. The core competencies have been integral in ABEM's development of Emergency Medicine Continuous Certification and the development of the Model of Clinical Practice of Emergency Medicine (Model). ABEM has used the Model as a significant part of its blueprint for the written and oral certification examinations in emergency medicine and is fully supportive of the effort to more fully define and integrate the ACGME core competencies into training emergency medicine specialists. To incorporate these competencies into our specialty, an Emergency Medicine Competency Taskforce (Taskforce) was formed by the Residency Review Committee-Emergency Medicine to determine how these general competencies fit in the Model. This article represents a consensus of the Taskforce with the input of multiple organizations in emergency medicine. It provides a framework for organizations such as the Council of Emergency Medicine Residency Directors (CORD) and the Society for Academic Emergency Medicine to develop a curriculum in emergency medicine and program requirement revisions by the Residency Review Committee-Emergency Medicine. In this report, we describe the approach taken by the Taskforce to integrate the ACGME core competencies into the Model. Ultimately, as competency-based assessment is implemented in emergency medicine training, program directors, governing bodies such as the ACGME, and individual patients can be assured that physicians are competent in emergency medicine.
• Swing, S. R., Sulton, L., Smith-coggins, R., Sanders, A. B., Perina, D. G., Laduca, T., Hayden, S. R., Dyne, P. L., Corrigan, K., Chinnis, A., Chapman, D. M., & Binder, L. S. (2004). Integrating the accreditation council for graduate medical education core competencies into the model of the clinical practice of emergency medicine. Annals of Emergency Medicine, 43(6), 756-769. doi:10.1016/j.annemergmed.2003.12.022
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  In response to public pressure for greater accountability from the medical profession, a transformation is occurring in the approach to medical education and assessment of physician competency. Over the past 5 years, the Accreditation Council for Graduate Medical Education (ACGME) has implemented the Outcomes and General Competencies projects to better ensure that physicians are appropriately trained in the knowledge and skills of their specialties. Concurrently, the American Board of Medical Specialties, including the American Board of Emergency Medicine (ABEM), has embraced the competency concept. The core competencies have been integral in ABEM's development of Emergency Medicine Continuous Certification and the development of the Model of Clinical Practice of Emergency Medicine (Model). ABEM has used the Model as a significant part of its blueprint for the written and oral certification examinations in emergency medicine and is fully supportive of the effort to more fully define and integrate the ACGME core competencies into training emergency medicine specialists. To incorporate these competencies into our specialty, an Emergency Medicine Competency Taskforce (Taskforce) was formed by the Residency Review Committee-Emergency Medicine to determine how these general competencies fit in the Model. This article represents a consensus of the Taskforce with the input of multiple organizations in emergency medicine. It provides a framework for organizations such as the Council of Emergency Medicine Residency Directors (CORD) and the Society for Academic Emergency Medicine to develop a curriculum in emergency medicine and program requirement revisions by the Residency Review Committee-Emergency Medicine. In this report, we describe the approach taken by the Taskforce to integrate the ACGME core competencies into the Model. Ultimately, as competency-based assessment is implemented in emergency medicine training, program directors, governing bodies such as the ACGME, and individual patients can be assured that physicians are competent in emergency medicine.
• Swing, S., Sulton, L., Smith-coggins, R., Sanders, A. B., Perina, D. G., Laduca, T., Hayden, S., Dyne, P., Corrigan, K., Chinnis, A., Chapman, D. M., & Binder, L. S. (2004). Integrating the Accreditation Council for Graduate Medical Education Core competencies into the model of the clinical practice of emergency medicine.. Annals of emergency medicine, 43(6), 756-69. doi:10.1016/s0196064403013532
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  In response to public pressure for greater accountability from the medical profession, a transformation is occurring in the approach to medical education and assessment of physician competency. Over the past 5 years, the Accreditation Council for Graduate Medical Education (ACGME) has implemented the Outcomes and General Competencies projects to better ensure that physicians are appropriately trained in the knowledge and skills of their specialties. Concurrently, the American Board of Medical Specialties, including the American Board of Emergency Medicine (ABEM), has embraced the competency concept. The core competencies have been integral in ABEM's development of Emergency Medicine Continuous Certification and the development of the Model of Clinical Practice of Emergency Medicine (Model). ABEM has used the Model as a significant part of its blueprint for the written and oral certification examinations in emergency medicine and is fully supportive of the effort to more fully define and integrate the ACGME core competencies into training emergency medicine specialists. To incorporate these competencies into our specialty, an Emergency Medicine Competency Taskforce (Taskforce) was formed by the Residency Review Committee-Emergency Medicine to determine how these general competencies fit in the Model. This article represents a consensus of the Taskforce with the input of multiple organizations in emergency medicine. It provides a framework for organizations such as the Council of Emergency Medicine Residency Directors (CORD) and the Society for Academic Emergency Medicine to develop a curriculum in emergency medicine and program requirement revisions by the Residency Review Committee-Emergency Medicine. In this report, we describe the approach taken by the Taskforce to integrate the ACGME core competencies into the Model. Ultimately, as competency-based assessment is implemented in emergency medicine training, program directors, governing bodies such as the ACGME, and individual patients can be assured that physicians are competent in emergency medicine.
• Swing, S., Sulton, L., Smith-coggins, R., Sanders, A. B., Perina, D. G., Laduca, T., Hayden, S., Dyne, P., Corrigan, K., Chinnis, A., Chapman, D. M., & Binder, L. S. (2004). Integrating the accreditation council for graduate medical education core competencies into the model of the clinical practice of emergency medicine.. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 11(6), 674-85.
• Sanders, A. B. (2003). Futility in resuscitation from cardiac arrest: role of out-of-hospital healthcare professionals.. The Journal of emergency medicine, 24(1), 87-9. doi:10.1016/s0736-4679(02)00682-0
• Sanders, A. B., Danzl, D. F., Slovis, C. M., Sanders, A. B., Perina, D. G., Danzl, D. F., Counselman, F. L., & Binder, L. S. (2003). The status of bedside ultrasonography training in emergency medicine residency programs.. Academic Emergency Medicine, 10(1), 37-42. doi:10.1197/aemj.10.1.37
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  Bedside ultrasonography (BU) is rapidly being incorporated into emergency medicine (EM) training programs and clinical practice. In the past decade, several organizations in EM have issued position statements on the use of this technology. Program training content is currently driven by the recently published “Model of the Clinical Practice of Emergency Medicine,” which includes BU as a necessary skill. Objective: The authors sought to determine the current status of BU training in EM residency programs. Methods: A survey was mailed in early 2001 to all 122 Accreditation Council for Graduate Medical Education (ACGME)-accredited EM residency programs. The survey instrument asked whether BU was currently being taught, how much didactic and hands-on training time was incorporated into the curriculum, and what specialty representation was present in the faculty instructors. In addition, questions concerning the type of tests performed, the number considered necessary for competency, the role of BU in clinical decision making, and the type of quality assurance program were included in the survey. Results: A total of 96 out of 122 surveys were completed (response rate of 79%). Ninety-one EM programs (95% of respondents) reported they teach BU, either clinically and/or didactically, as part of their formal residency curriculum. Eighty-one (89%) respondents reported their residency program or primary hospital emergency department (ED) had a dedicated ultrasound machine. BU was performed most commonly for the following: the FAST scan (focused abdominal sonography for trauma, 79/87%); cardiac examination (for tamponade, pulseless electrical activity, etc., 65/71%); transabdominal (for intrauterine pregnancy, ectopic pregnancy, etc., 58/64%); and transvaginal (for intrauterine pregnancy, ectopic pregnancy, etc., 45/49%). One to ten hours of lecture on BU was provided in 43%, and one to ten hours of hands-on clinical instruction was provided in 48% of the EM programs. Emergency physicians were identified as the faculty most commonly involved in teaching BU to EM residents (86/95%). Sixty-one (69%) programs reported that EM faculty and/or residents made clinical decisions and patient dispositions based on the ED BU interpretation alone. Fourteen (19%) programs reported that no formal quality assurance program was in place. Conclusions: The majority of ACGME-accredited EM residency programs currently incorporate BU training as part of their curriculum. The majority of BU instruction is done by EM faculty. The most commonly performed BU study is the FAST scan. The didactic component and clinical time devoted to BU instruction are variable between programs. Further standardization of training requirements between programs may promote increasing standardization of BU in future EM practice.
• Xavier, L. C., Sanders, A. B., Kern, K. B., Hilwig, R. W., Ewy, G. A., & Berg, R. A. (2003). Automated external defibrillation versus manual defibrillation for prolonged ventricular fibrillation: lethal delays of chest compressions before and after countershocks.. Annals of emergency medicine, 42(4), 458-67. doi:10.1067/s0196-0644(03)00525-0
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  We sought to determine whether the delays in chest compressions and defibrillation associated with an automated external defibrillator would adversely affect outcome compared with manual defibrillation in a swine model of out-of-hospital prolonged ventricular fibrillation..After 8 minutes of untreated ventricular fibrillation, 16 swine (33+/-4 kg) were randomly assigned to automated external defibrillator defibrillation or manual defibrillation with the same biphasic truncated exponential waveform 150-J shock through the same type of pads. Defibrillation with the automated external defibrillator was performed as recommended by the manufacturer, and manual defibrillation was provided per American Heart Association Guidelines. The primary outcome measure was 24-hour survival with good neurologic outcome. Data are described as means+/-SD..None of 8 animals in the automated external defibrillator group survived for 24 hours, whereas 5 of 8 animals in the manual defibrillation group survived 24 hours, all with good neurologic outcome (P=.027). The time interval from simulated defibrillator arrival to first compressions was 98+/-18 seconds in the automated external defibrillator group versus 68+/-15 seconds in the manual defibrillation group. In particular, the interval from first shock to first chest compressions was 46+/-18 seconds versus 22+/-16 seconds, respectively. The mean percentage of time that chest compressions were performed in the first minute after the first countershock was 15%+/-13% versus 40%+/-15%, respectively. As a result, return of spontaneous circulation within 5 minutes of simulated defibrillator arrival occurred in only 1 of 8 animals in the automated external defibrillator group versus 6 of 8 animals in the manual defibrillation group..The longer delays in chest compressions with automated external defibrillator defibrillation versus manual defibrillation can worsen the outcome from prolonged ventricular fibrillation.
• Sanders, A. B. (2002). COMMENTARIES: Quality in Emergency Medicine: An Introduction. Academic Emergency Medicine, 9(11), 1064-1066. doi:10.1197/aemj.9.11.1064
• Sanders, A. B. (2002). Missed delirium in older emergency department patients: a quality-of-care problem.. Annals of emergency medicine, 39(3), 338-41. doi:10.1067/mem.2002.122273
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  Abstract Sanders AB. Missed delirium in older emergency department patients: a quality-of-care problem. Ann Emerg Med. March 2002;39:338-341.
• Sanders, A. B. (2002). Quality in emergency medicine: an introduction.. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 9(11), 1064-6. doi:10.1111/j.1553-2712.2002.tb01557.x
• Sanders, A. B., Kern, K. B., Hilwig, R. W., Ewy, G. A., & Berg, R. A. (2002). Importance of continuous chest compressions during cardiopulmonary resuscitation: improved outcome during a simulated single lay-rescuer scenario.. Circulation, 105(5), 645-9. doi:10.1161/hc0502.102963
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  Interruptions to chest compression-generated blood flow during cardiopulmonary resuscitation (CPR) are detrimental. Data show that such interruptions for mouth-to-mouth ventilation require a period of "rebuilding" of coronary perfusion pressure to obtain the level achieved before the interruption. Whether such hemodynamic compromise from pausing to ventilate is enough to affect outcome is unknown..Thirty swine (weight 35 +/- 2 kg) underwent 3 minutes of untreated ventricular fibrillation before 12 minutes of basic life support CPR. Animals were randomized to receive either standard airway (A), breathing (B), and compression (C) CPR with expired-gas ventilation in a 15:2 compression-to-ventilation ratio or continuous chest compression CPR. Those randomized to the standard 15:2 group had no chest compressions for a period of 16 seconds each time the 2 ventilations were delivered. Defibrillation was attempted at 15 minutes of cardiac arrest. All resuscitated animals were supported in an intensive care environment for 1 hour, then in a maintenance facility for 24 hours. The primary end point of neurologically normal 24-hour survival was significantly better in the experimental group receiving continuous chest compression CPR (12 of 15 versus 2 of 15; P
• Sanders, A. B., Kern, K. B., Hilwig, R. W., Heidenrich, J., Ewy, G. A., & Berg, R. A. (2002). Survival and neurologic outcome after cardiopulmonary resuscitation with four different chest compression-ventilation ratios.. Annals of emergency medicine, 40(6), 553-62. doi:10.1067/mem.2002.129507
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  The optimal ratio of chest compressions to ventilations during cardiopulmonary resuscitation (CPR) is unknown. We determine 24-hour survival and neurologic outcome, comparing 4 different chest compression-ventilation CPR ratios in a porcine model of prolonged cardiac arrest and bystander CPR..Forty swine were instrumented and subjected to 3 minutes of ventricular fibrillation followed by 12 minutes of CPR by using 1 of 4 models of chest compression-ventilation ratios as follows: (1) standard CPR with a ratio of 15:2; (2) CC-CPR, chest compressions only with no ventilations for 12 minutes; (3) 50:5-CPR, CPR with a ratio of 50:5 compressions to ventilations, as advocated by authorities in Great Britain; and (4) 100:2-CPR, 4 minutes of chest compressions only followed by CPR with a ratio of 100:2 compressions to ventilations. CPR was followed by standard advanced cardiac life support, 1 hour of critical care, and 24 hours of observation, followed by a neurologic evaluation..There were no statistically significant differences in 24-hour survival among the 4 groups (standard CPR, 7/10; CC-CPR, 7/10; 50:5-CPR, 8/10; 100:2-CPR, 9/10). There were significant differences in 24-hour neurologic function, as evaluated by using the swine cerebral performance category scale. The animals receiving 100:2-CPR had significantly better neurologic function at 24 hours than the standard CPR group with a 15:2 ratio (1.5 versus 2.5; P =.007). The 100:2-CPR group also had better neurologic function than the CC-CPR group, which received chest compressions with no ventilations (1.5 versus 2.3; P =.027). Coronary perfusion pressures, aortic pressures, and myocardial and kidney blood flows were not significantly different among the groups. Coronary perfusion pressure as an integrated area under the curve was significantly better in the CC-CPR group than in the standard CPR group (P =.04). Minute ventilation and PaO (2) were significantly lower in the CC-CPR group..In this experimental model of bystander CPR, the group receiving compressions only for 4 minutes followed by a compression-ventilation ratio of 100:2 achieved better neurologic outcome than the group receiving standard CPR and CC-CPR. Consideration of alternative chest compression-ventilation ratios might be appropriate.
• Vanlandingham, B. D., & Sanders, A. B. (2002). Acute ischemic syndromes. Early response.. Cardiology clinics, 20(1), 103-16. doi:10.1016/s0733-8651(03)00068-7
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  The optimal treatment of patients with AIS depends on a well-run, integrated system of care involving patients and teams of health care professionals. It begins with patient education and extends to a method for accessing an efficient and effective EMS system. Medics must be well equipped and well trained to evaluate and begin initial treatment during prompt transport to an appropriate hospital. The role of out-of-hospital 12-lead ECGs and thrombolysis is reviewed and may be appropriate for some EMS systems. The initial evaluation and treatment in the ED goes on simultaneously and is a dynamic process. Prompt treatment with oxygen, nitroglycerin, morphine, and aspirin is indicated. Initial risk stratification is based on the first ECG, cardiac biomarkers, and the clinical history and physical exam. Disposition and further evaluation is individualized according to the initial work-up and risk assessment.
• Xavier, L. C., Sanders, A. B., Kern, K. B., Hilwig, R. W., Ewy, G. A., & Berg, R. A. (2002). Superior outcome with immediate manual defibrillation versus automated external defibrillation in a swine model of prehospital ventricular fibrillation cardiac arrest. Journal of the American College of Cardiology, 39, 282. doi:10.1016/s0735-1097(02)81263-3
• Sanders, A. B. (2001). Older persons in the emergency medical care system.. Journal of the American Geriatrics Society, 49(10), 1390-2. doi:10.1046/j.1532-5415.2001.49272.x
• Sanders, A. B., Kern, K. B., & Berg, R. A. (2001). Searching for a predictive rule for terminating cardiopulmonary resuscitation.. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 8(6), 654-7. doi:10.1111/j.1553-2712.2001.tb00180.x
• Sanders, A. B., Porter, M. E., Kern, K. B., Hilwig, R. W., Heidenreich, J. W., Ewy, G. A., & Berg, R. A. (2001). Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest.. Circulation, 104(20), 2465-70. doi:10.1161/hc4501.098926
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  Despite improving arterial oxygen saturation and pH, bystander cardiopulmonary resuscitation (CPR) with chest compressions plus rescue breathing (CC+RB) has not improved survival from ventricular fibrillation (VF) compared with chest compressions alone (CC) in numerous animal models and 2 clinical investigations..After 3 minutes of untreated VF, 14 swine (32+/-1 kg) were randomly assigned to receive CC+RB or CC for 12 minutes, followed by advanced cardiac life support. All 14 animals survived 24 hours, 13 with good neurological outcome. For the CC+RB group, the aortic relaxation pressures routinely decreased during the 2 rescue breaths. Therefore, the mean coronary perfusion pressure of the first 2 compressions in each compression cycle was lower than those of the final 2 compressions (14+/-1 versus 21+/-2 mm Hg, P
• Wyllie, J., Sanders, A. B., Phillips, B., Kinney, S., Handley, A. J., Gerardi, M. J., Ewy, G. A., Doherty, A., Cobb, L. A., & Berg, R. A. (2001). Chest compressions and basic life support-defibrillation.. Annals of emergency medicine, 37(4 Suppl), S26-35. doi:10.1067/mem.2001.114173
• Sanders, A. B., Klasco, R. S., Handler, J. A., & Gillam, M. (2000). Defining, identifying, and measuring error in emergency medicine.. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 7(11), 1183-8. doi:10.1111/j.1553-2712.2000.tb00462.x
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  The findings of a consensus committee created to address the definition, measurement, and identification of error in emergency medicine (EM) are presented. The literature of error measurement in medicine is also reviewed and analyzed. The consensus committee recommended adopting a standard set of terms found in the medical error literature. Issues surrounding error identification are discussed. The pros and cons of mandatory reporting, voluntary reporting, and surveillance systems are addressed, as is error reporting at the clinician, hospital, and oversight group levels. Committee recommendations are made regarding the initial steps EM should take to address error. The establishment of patient safety boards at each institution is also recommended.
• Sanders, A. B., Otto, C. W., Kern, K. B., Hilwig, R. W., Ewy, G. A., & Berg, R. A. (2000). Catecholamines in cardiac arrest: role of alpha agonists, beta-adrenergic blockers and high-dose epinephrine.. Resuscitation, 47(2), 203-8. doi:10.1016/s0300-9572(00)00261-6
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  Once initial defibrillation has failed, the advanced cardiac life support (ACLS) guidelines for cardiopulmonary resuscitation (CPR) recommend periodic intravenous administration of epinephrine to increase coronary artery perfusion pressure (CPP) via arterial vasoconstriction to [1]. During prolonged cardiac arrest coronary perfusion pressure and forward blood flow are the major determinants of successful resuscitation, for when CPP is too low, successful resuscitation is unlikely. When the CPP is marginal, resuscitation may be possible; however, 24-h survival is unlikely [2]. When CPR is able to generate CPP above 30 mmHg associated with adequate forward blood flow as reflected in an adequate end-tidal CO2 the 24-h survival rate is greatly improved [2]. The American Heart Association ACLS guidelines recommend epinephrine as the pressor agent of choice during prolonged CPR [1]. These recommendations are based on now classic works [2–8]. Yet, studies have accumulated over the years that have raised concern that epinephrine’s beta-adrenergic effect may increase the myocardial oxygen consumption of the fibrillating heart and predispose to post-defibrillation dysfunction and cardiac arrhythmias [9–16]. Added to this concern was the finding that endogenous catecholamine concentrations are high during ventricular fibrillation even in the absence of epinephrine administration [11]. Ditchey and associates found, in a canine ventricular fibrillation cardiac arrest model, that the balance between myocardial oxygen supply and demand was improved by the administration of propranolol and phenylephrine, an exogenous selective alpha-agonist [9]. The limitations of these studies, however, is that high-dose epinephrine was used and survival was not evaluated. High-dose epinephrine administered during resuscitation initially appeared to be useful, producing higher perfusion pressures, but high-dose epinephrine has not been shown in clinical trials [17,18] nor in some experimental trials [12,13] to improve survival. Studies from our laboratory found that high-dose epinephrine resulted in postresuscitative tachycardia, systemic hypertension and greater early mortality relative to the standard dose [12]. Other laboratories have also documented adverse effects of high-dose epinephrine when given during CPR, including post-resuscitation hyperadrenergic state [14], myocardial necrosis [15], and worsened post-arrest cardiomyopathy [16]. Although pure alpha-agonists have not been shown to be superior to epinephrine [19–22], one could speculate that a combination of an alpha-adrenergic agonist and a beta-blocker might improve hemodynamics during CPR and thus improve long-term survival while avoiding the post resuscitation problem of excessive beta stimulation. * Correspnding author. Tel.: +1-520-626-7383.
• Sanders, A. B. (1999). Changing clinical practice in geriatric emergency medicine.. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 6(12), 1189-93. doi:10.1111/j.1553-2712.1999.tb00131.x
• Sanders, A. B. (1999). Do we need a clinical decision rule for the discontinuation of cardiac arrest resuscitations?. Archives of internal medicine, 159(2), 119-21. doi:10.1001/archinte.159.2.119
• Cummins, R. O., Chamberlain, D., Callanan, V., Carli, P., Connolly, B., Steen, P., Sanders, A. B., Ornato, J. P., Kloeck, W., Christenson, J., & Bossaert, L. (1998). Situações especiais de ressuscitação.. Arquivos Brasileiros De Cardiologia, 71, 29-42.
• Kloeck, W., Christenson, J., Steen, P., Steen, P. A., Sanders, A. B., Ornato, J. P., Kloeck, W., Cummins, R. O., Connolly, B., Christenson, J., Chamberlain, D., Carli, P., Callanan, V., & Bossaert, L. (1998). [Special situations in resuscitation].. Arquivos brasileiros de cardiologia, 71 Suppl 1, 29-42.
• Sanders, A. B., Lewis, R. J., Biros, M. H., & Barsan, W. G. (1998). Supporting emergency medicine research: developing the infrastructure.. Annals of emergency medicine, 31(2), 188-96. doi:10.1016/s0196-0644(98)70327-0
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  The long-term goals of developing research within the specialty of emergency medicine include the following: (1) to continue to improve the quality and quantity of emergency patient care; (2) to maximize the research potential of emergency health care professionals to develop new emergency research talent and enthusiasm; and (3) to establish the academic research credentials of the specialty of emergency medicine to become competitive for federal research funding, and further improve emergency patient care. This article addresses the process by which the infrastructure for emergency medicine research can be developed at academic medical centers and provides recommendations. The roles of the academic chair, research director, senior researcher, and departmental faculty are discussed.
• Sanders, T., & Sanders, A. B. (1998). Advanced Cardiac Life Support education: translating scientific guidelines into clinical practice.. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 5(7), 655-6. doi:10.1111/j.1553-2712.1998.tb02480.x
• W, K., Steen, P., Sanders, A. B., Ornato, J. P., L, B., Kloeck, W., J, C., Cummins, R. O., Connolly, B., Christenson, J., Chamberlain, D., Carli, P., Callanan, V., Callanan, C., & Bossaert, L. (1998). [Universal algorithm for advanced life support].. Arquivos brasileiros de cardiologia, 71 Suppl 1, 15-6.
• Zaritsky, A., Steen, P. A., Sanders, A. B., Robertson, C., Ornato, J. P., Nadkarni, V., Kramer, E., Koster, R., Kloeck, W., Idris, A. H., Hazinski, M. F., Cummins, R. O., Connolly, B., Cobbe, S., Chamberlain, D., Callanan, V., Bossaert, L., Backer, L., & Allen, M. (1998). In-hospital resuscitation: A statement for healthcare professionals from the American Heart Association Emergency Cardiac Care Committee and the advanced cardiac life support, basic life support, pediatric resuscitation, and program administration subcommittees. Respiratory Care, 43(1), 30-32.
• Berg, M. D., Sanders, A. B., Otto, C. W., Kern, K. B., Hilwig, R. W., Ewy, G. A., Berg, R. A., & Berg, M. D. (1997). Assisted ventilation does not improve outcome in a porcine model of single-rescuer bystander cardiopulmonary resuscitation.. Circulation, 95(6), 1635-41. doi:10.1161/01.cir.95.6.1635
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  Mouth-to-mouth rescue breathing is a barrier to the performance of bystander cardiopulmonary resuscitation (CPR). We evaluated the need for assisted ventilation during simulated single-rescuer bystander CPR in a swine model of prehospital cardiac arrest..Five minutes after ventricular fibrillation, swine were randomly assigned to 8 minutes of hand-bag-valve ventilation with 17% oxygen and 4% carbon dioxide plus chest compressions (CC + V), chest compressions only (CC), or no CPR (control group). Standard advanced life support was then provided. Animals successfully resuscitated received 1 hour of intensive care support and were observed for 24 hours. All 10 CC animals, 9 of the 10 CC + V animals, and 4 of the 6 control animals attained return of spontaneous circulation. Five of the 10 CC animals, 6 of the 10 CC + V animals, and none of the 6 control animals survived for 24 hours (CC versus controls, P = .058; CC + V versus controls, P < .03). All 24-hour survivors were normal or nearly normal neurologically..In this model of prehospital single-rescuer bystander CPR, successful initial resuscitation, 24-hour survival, and neurological outcome were similar after chest compressions only or chest compressions plus assisted ventilation. Both techniques tended to improve outcome compared with no bystander CPR.
• Robertson, C. E., Zaritsky, A., Steen, P., Sanders, A. B., Robertson, C., Ornato, J. P., Nadkarni, V., Kramer, E., Koster, R., Kloeck, W., Idris, A. H., Hazinski, M. F., Cummins, R. O., Connolly, B., Cobbe, S., Chamberlain, D., Callanan, V., Bossaert, L., Becker, L. B., & Allen, M. (1997). Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: the in-hospital 'Utstein style'. A statement for healthcare professionals from the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, the Australian Resuscitation Council, and the Resuscitation Councils of Southern Africa.. Resuscitation, 34(2), 151-83. doi:10.1016/s0300-9572(97)01112-x
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  This scientific statement is the product of the Utstein ’95 Symposium held June 23-24, 1995, at Utstein Abbey, Island of Mosteroy, Rogaland County, Norway. Draft versions were circulated for comment to participants of the Utstein ’95 Symposium; the European Resuscitation Council Executive Committee; the Emergency Cardiac Care Committee of the American Heart Association; the Executive Committees of the Heart and Stroke Foundation of Canada, the Australian Resuscitation Council, and the Resuscitation Councils of Southern Africa; and several outside reviewers. The development of this statement was authorized by the Science Advisory and Coordinating Committee of the AHA and the Executive Committee of the European Resuscitation Council. We do not know the true effectiveness of in-hospital resuscitation. Observed results of the many published studies vary greatly. Studies originate from different settings and have different patient populations. Reports suffer from nonuniform nomenclature and variable inclusion definitions. Patients differ in the extent of comorbid conditions and interventions in place at the time of cardiac arrest. These differences prevent valid interhospital and intrahospital comparisons and make determining the effectiveness of current resuscitation techniques impossible. To develop these guidelines the task force used a consensus development process that originated with the “Utstein style” for reporting outcome data from out-of-hospital resuscitation events. Task force members performed an integrated review of published studies. An initial draft was prepared, discussed, and revised at a 2-day conference. Further drafts were revised and circulated among task force members and discussed face-to-face at three subsequent meetings. The task force defined a set of data elements that are essential or desirable for documenting in-hospital cardiac arrest. Data categories are hospital variables, patient variables, arrest variables, and outcome variables. The “In-Hospital Utstein-Style Template” was developed to summarize these data and recommendations for reporting a specific set of survival rates and outcomes. The task force …
• Robertson, C. E., Zaritsky, A., Steen, P., Sanders, A. B., Robertson, C., Ornato, J. P., Nadkarni, V., Kramer, E., Koster, R., Kloeck, W., Idris, A. H., Hazinski, M. F., Cummins, R. O., Connolly, B., Cobbe, S., Chamberlain, D., Callanan, V., Bossaert, L., Becker, L. B., & Allen, M. (1997). Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: the in-hospital "Utstein style". American Heart Association.. Annals of emergency medicine, 29(5), 650-79. doi:10.1016/s0196-0644(97)70256-7
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  Abstract [Utstein Style Writing Group: Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: The in-hospital "Utstein style." Ann Emerg Med May 1997;29:650-679.]
• Sanders, A. B. (1997). Emergency care for patients in long-term care facilities: a need for better communication.. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 4(9), 854-5. doi:10.1111/j.1553-2712.1997.tb03807.x
• Sanders, A. B. (1997). When are resuscitation attempts futile?. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 4(9), 852-3. doi:10.1111/j.1553-2712.1997.tb03806.x
• Sanders, A. B., Mancini, E., Hazinski, M. F., & Cummins, R. O. (1997). In-hospital resuscitation: a statement for healthcare professionals from the American Heart Association Emergency Cardiac Care Committee and the Advanced Cardiac Life Support, Basic Life Support, Pediatric Resuscitation, and Program Administration Subcommittees.. Circulation, 95(8), 2211-2. doi:10.1161/01.cir.95.8.2211
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  The Emergency Cardiac Care (ECC) Committee of the American Heart Association first published guidelines for cardiopulmonary resuscitation (CPR) and ECC in 1974.1 Updated in 1980, 1986, and 1992, the AHA guidelines are now recognized as the world’s most authoritative resuscitation guidelines.2 3 4 To implement these guidelines, however, hospitals need to establish a systems approach to in-hospital resuscitation rather than depend on the skills of individual professionals. The success and acceptance of the out-of-hospital Utstein-style recommendations5 led the AHA to help develop specific recommendations for documenting in-hospital resuscitation. The Utstein-style recommendations for uniform reporting of in-hospital resuscitations present important recommendations for all hospital facilities.6 With publication of these recommendations, members of the ECC Committee recognized the need to summarize the major actions that enable a hospital to fulfill the resuscitation recommendations. CPR is one of the few interventions that requires an order to not be administered. Resuscitation efforts, however, are not appropriate for all hospital patients. When indicated, healthcare providers discuss with patients, families, and surrogate decision-makers their options and preferences for resuscitation. Hospitals have in place clear policies that address medical futility, patient self-determination, and do-not-attempt-resuscitation orders. The chain of survival, first conceptualized for out-of-hospital sudden cardiac arrest,7 applies to in-hospital arrest as well.8 …
• Sanders, A. B., Rhee, K. H., Otto, C. W., Kern, K. B., Hilwig, R. W., Ewy, G. A., & Berg, R. A. (1997). Postresuscitation left ventricular systolic and diastolic dysfunction. Treatment with dobutamine.. Circulation, 95(12), 2610-3. doi:10.1161/01.cir.95.12.2610
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  Global left ventricular dysfunction after successful resuscitation is well documented and appears to be a major contributing factor in limiting long-term survival after initial recovery from out-of-hospital sudden cardiac death. Treatment of such postresuscitation myocardial dysfunction has not been examined previously..Systolic and diastolic parameters of left ventricular function were measured in 27 swine before and after successful resuscitation from prolonged ventricular fibrillation cardiac arrest. Dobutamine infusions (10 micrograms.kg-1.min-1 in 14 animals or 5 micrograms.kg-1.min-1 in 5 animals) begun 15 minutes after resuscitation were compared with controls receiving no treatment (8 animals). The marked deterioration in systolic and diastolic left ventricular function seen in the control group after resuscitation was ameliorated in the dobutamine-treated animals. Left ventricular ejection fraction fell from a prearrest 58 +/- 3% to 25 +/- 3% at 5 hours after resuscitation in the control group but remained unchanged in the dobutamine (10 micrograms.kg-1.min-1) group (52 +/- 1% prearrest and 55 +/- 3% at 5 hours after resuscitation). Measurement of the constant of isovolumic relaxation of the left ventricle (tau) demonstrated a similar benefit of the dobutamine infusion for overcoming postresuscitation diastolic dysfunction. The tau rose in the controls from 28 +/- 1 milliseconds (ms) prearrest to 41 +/- 3 ms at 5 hours after resuscitation whereas it remained constant in the dobutamine-treated animals (31 +/- 1 ms prearrest and 31 +/- 5 ms at 5 hours after resuscitation)..Dobutamine begun within 15 minutes of successful resuscitation can successfully overcome the global systolic and diastolic left ventricular dysfunction resulting from prolonged cardiac arrest and cardiopulmonary resuscitation.
• Steen, P. A., Sanders, A. B., Ornato, J. P., Kloeck, W., Cummins, R. O., Connolly, B., Christenson, J., Chamberlain, D., Carli, P., Callanan, V., & Bossaert, L. (1997). Early defibrillation: an advisory statement from the Advanced Life Support Working Group of the International Liaison Committee on Resuscitation.. Circulation, 95(8), 2183-4. doi:10.1161/01.cir.95.8.2183
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  Most adults who can be saved from cardiac arrest are in ventricular fibrillation (VF) or pulseless ventricular tachycardia. Electrical defibrillation provides the single most important therapy for the treatment of these patients. Resuscitation science therefore places great emphasis on early defibrillation. The greatest chances of survival result when the interval between the start of VF and the delivery of defibrillation is as brief as possible. To achieve the earliest possible defibrillation, the International Liaison Committee on Resuscitation (ILCOR) endorses the concept that in many settings nonmedical individuals should be allowed and encouraged to use defibrillators. ILCOR recommends that resuscitation personnel be authorized, trained, equipped, and directed to operate a defibrillator if their professional responsibilities require them to respond to persons in cardiac arrest. This recommendation includes all first-responding emergency personnel, in both the hospital and out-of-hospital settings, whether physicians, nurses, or nonmedical ambulance personnel. The widespread availability of automated external defibrillators (AEDs) provides the technological capacity for early defibrillation by both ambulance crews and lay responders. ILCOR urges the medical profession to strive to increase the awareness of the public and of those responsible for emergency medical …
• Steen, P. A., Sanders, A. B., Ornato, J. P., Kloeck, W., Cummins, R. O., Connolly, B., Christenson, J., Chamberlain, D., Carli, P., Callanan, V., & Bossaert, L. (1997). The Universal ALS algorithm. An advisory statement by the Advanced Life Support Working Group of the International Liaison Committee on Resuscitation.. Resuscitation, 34(2), 109-11. doi:10.1016/s0300-9572(97)01100-3
• Witzke, D. B., & Sanders, A. B. (1997). The development and evaluation of a geriatric emergency medicine curriculum. The SAEM Geriatric Emergency Medicine Task Force.. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 4(3), 219-22. doi:10.1111/j.1553-2712.1997.tb03745.x
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  To summarize the processes used to develop a curriculum and model of care for the emergency medical treatment of elder patients and to assess the efficacy of the teaching material in a pilot course..A survey of emergency medicine (EM) residency directors and geriatric fellowship directors was used to identify key topics for inclusion in the didactic material. An interdisciplinary consensus process was used to develop didactic as well as teaching material in geriatric EM. Pretests and posttests were administered to 46 participants in the initial course to assess knowledge gain. Subjective course evaluations were also done..Test scores significantly increased from 54% correct on the pretest to 77% correct on the posttest (p < 0.001). Significant improvement in knowledge as judged by pretest and posttest results occurred in 6 of the 7 teaching modules. Subjective evaluations demonstrated good to excellent ratings for each module as well as the overall workshop..The process of developing a curriculum for geriatric EM is described. The initial training of instructors was effective in improving participants' knowledge of geriatric issues in EM. Participants considered the training to be effective. The effect of the training on the emergency care of elder persons remains to be determined.
• Zaritsky, A., Steen, P. A., Sanders, A. B., Robertson, C., Ornato, J. P., Nadkarni, V., Kramer, E., Koster, R., Kloeck, W., Idris, A. H., Hazinski, M. F., Cummins, R. O., Connolly, B., Cobbe, S., Chamberlain, D., Callanan, V., Bossaert, L., Becker, L. B., & Allen, M. (1997). Recommended guidlines for reviewing, reporting, and conducting research on in-hospital resuscitation: The in-hospital 'Utstein style'. Academic Emergency Medicine, 4(6), 603-627. doi:10.1111/j.1553-2712.1997.tb03586.x
• Davis, M. F., Sanders, A. B., Milander, M. M., Locke, C. J., Kern, K. B., Ewy, G. A., Davis, M. F., & Berg, R. A. (1996). Bystander cardiopulmonary resuscitation : concerns about mouth-to-mouth contact. Resuscitation, 31(2), 164. doi:10.1016/0300-9572(96)83764-6
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  Background: Bystander cardiopulmonary resuscitation (CPR) is performed on only a small percentage of patients who suffer cardiac arrest. We conducted a study to elucidate attitudes toward and potential obstacles to performance of bystander CPR. Methods: Attitude survey of 975 people on the University Heart Center, University of Arizona, Tucson, mailing list. Participants were asked about their willingness to perform CPR under four conditions, with varying relationships (stranger vs relative or friend) and CPR techniques (chest compressions plus mouth-to-mouth ventilation [CC+V] vs chest compressions alone [CC]). Results: Participants rated willingness to perform CPR and concern about disease transmission. Both relationship and CPR technique affected willingness to respond. Only 15% would «definitely» provide CC+V with strangers compared with 68% who would «definitely» perform CC. Even with relatives or friends, only 74% would «definitely» provide CC+V compared with 88% who would «definitely» provide CC. Eighty-two percent of participants were at least «moderately» concerned about disease transmission. Conclusion: Concerns regarding mouth-to-mouth ventilation appear to create substantial barriers to performance of bystander CPR. Intensified educational efforts and investigations of new approaches to bystander CPR are warranted
• Sanders, A. B. (1996). Emergency department utilization by elder persons.. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 3(7), 658-9. doi:10.1111/j.1553-2712.1996.tb03486.x
• Sanders, A. B. (1996). The training of emergency medical technicians in geriatric emergency medicine.. The Journal of emergency medicine, 14(4), 499-500. doi:10.1016/0736-4679(96)00087-x
• Sanders, A. B., Otto, C. W., Kern, K. B., Hilwig, R. W., Figge, G., Ewy, G. A., & Berg, R. A. (1996). Active compression-decompression versus standard cardiopulmonary resuscitation in a porcine model: no improvement in outcome.. American heart journal, 132(6), 1156-62. doi:10.1016/s0002-8703(96)90458-5
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  Active compression-decompression cardiopulmonary resuscitation (CPR) is a new innovative basic life-support technique during which the anterior chest wall is actively decompressed by a suction device. CPR techniques were studied in 36 swine to test the hypothesis that active compression-decompression CPR improves coronary perfusion pressure, myocardial blood flow during CPR, and 24-hour survival. After 30 seconds of untreated ventricular fibrillation, CPR was begun and continued for 12.5 minutes by one of the three following methods: (1) active compression-decompression CPR with a suction device modified to include a precision force transducer; (2) standard CPR performed with a force transducer device; and (3) standard manual CPR performed without a force transducer device. CPR-generated coronary perfusion pressure, myocardial blood flow, and the force of compression were measured at 3 and 10 minutes of resuscitation effort. Initial return of spontaneous circulation, 24-hour survival, and trauma scores were also evaluated. Active compression-decompression CPR produced consistently better results than did standard CPR performed with a force transducer, but not better than standard CPR performed manually without a force transducer. The use of a force-measuring device with standard CPR may compromise hemodynamic response and outcome.
• Sanders, A. B., Otto, C. W., Kern, K. B., Hilwig, R. W., Henry, C. P., Ewy, G. A., & Berg, R. A. (1996). A randomized, blinded trial of high-dose epinephrine versus standard-dose epinephrine in a swine model of pediatric asphyxial cardiac arrest.. Critical care medicine, 24(10), 1695-700. doi:10.1097/00003246-199610000-00016
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  To determine whether high-dose epinephrine administration during cardiopulmonary resuscitation (CPR) in a swine pediatric asphyxial cardiac arrest model improves outcome (i.e., resuscitation rate, survival rate, and neurologic function) compared with standard-dose epinephrine..A randomized, blinded study..A large animal cardiovascular laboratory at a university..Thirty domestic piglets (3 to 4 months of age) were randomized to receive standard-dose epinephrine (0.02 mg/kg) or high-dose epinephrine (0.2 mg/kg) during CPR after 10 mins of cardiac standstill with loss of aortic pulsation after endotracheal tube clamping..Two minutes of CPR were provided, followed by advanced pediatric life support. Successfully resuscitated animals were supported in an intensive care unit (ICU) setting for 2 hrs and then observed for 24 hrs..Electrocardiogram, thoracic aortic blood pressure, and right atrial blood pressure were monitored continuously until the intensive care period ended. Survival rate and neurologic outcome were determined. Return of spontaneous circulation was obtained in 13 of 15 high-dose epinephrine piglets vs. ten of 15 standard-dose epinephrine piglets (p < .20). Four of 13 high-dose piglets died in the ICU period after initial resuscitation vs. 0 of ten standard-dose piglets (p < or = .05). Nine high-dose piglets survived 2 hrs vs. ten standard-dose piglets. Three piglets in each group survived for 24 hrs, but all were severely neurologically impaired. Two minutes after resuscitation, piglets treated with high-dose epinephrine had higher heart rates (210 +/- 24 vs. 189 +/- 40 beats/min, p < .05) and higher aortic diastolic pressures (121 +/- 39 vs. 74 +/- 40 mm Hg, p < .01). Within 10 mins of return of spontaneous circulation, severe tachycardia (> 240 beats/min) was more frequently noted in the high-dose group than in the standard-dose group (p < .05). All four high-dose piglets that died in the ICU period experienced ventricular fibrillation within 10 mins of return of spontaneous circulation..High-dose epinephrine did not improve 2-hr survival rate, 24-hr survival rate, or neurologic outcome. High-dose epinephrine resulted in severe tachycardia and hypertension immediately after resuscitation and in a higher mortality rate immediately after resuscitation.
• Sanders, A. B., Otto, C. W., Kern, K. B., Hilwig, R. W., Henry, C. P., Ewy, G. A., & Berg, R. A. (1996). Initial end-tidal CO2 is markedly elevated during cardiopulmonary resuscitation after asphyxial cardiac arrest.. Pediatric emergency care, 12(4), 245-8. doi:10.1097/00006565-199608000-00002
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  To compare the initial end-tidal CO2 (PetCO2) during cardiopulmonary resuscitation in asphyxial versus ventricular fibrillatory cardiac arrest..A cohort study..University research laboratory..Forty domestic piglets..Asphyxial cardiac arrest was produced by clamping the endotracheal tube in 20 piglets and was continued for 10 minutes after loss of aortic pulsations occurred. Ventricular fibrillation (VF) was induced by applying 60 Hz of alternating current via a pacing wire to the myocardium of the other 20 piglets, and continued for a 15-minute downtime. Cardiopulmonary resuscitation (CPR) was then provided to each group for two minutes, followed by standard advanced cardiac life support protocols..All piglets were instrumented for continuous monitoring of PetCO2, electrocardiogram, central venous pressure, and aortic pressure. PetCO2 of the first breath of CPR was 91 +/- 20 mmHg in the asphyxial group versus 34 +/- 14 mmHg in the VF group (P < 0.001). The asphyxial group continued to exhibit significantly greater PetCO2 for the first five breaths of resuscitation, after which there were no differences. The coronary perfusion pressures during the first breaths of CPR did not differ between the two groups. High initial PetCO2 did not correlate with return of spontaneous circulation..End-tidal CO2 during the first five breaths of CPR is much higher after an asphyxial cardiac arrest than VF. In each case, the initial PetCO2 appears to reflect alveolar CO2 prior to CPR. After one minute of CPR, PetCO2 is useful in monitoring the effectiveness of CPR.
• Sanders, A. B., Samson, R. A., Otto, C. W., Kern, K. B., Ewy, G. A., & Berg, R. A. (1996). Ventricular fibrillation in a swine model of acute pediatric asphyxial cardiac arrest.. Resuscitation, 33(2), 147-53. doi:10.1016/s0300-9572(96)01013-1
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  To determine cardiac rhythms in a swine model of acute pediatric asphyxial cardiac arrest..Prospective electrocardiographic evaluation of 36 piglets..University hospital laboratory..Piglets were acutely asphyxiated by endotracheal tube clamping until 10 min after loss of aortic pulsations. Resuscitative efforts were then provided..None of the animals had ventricular fibrillation (VF) when loss of aortic pulsations occurred (11 +/- 2 min after clamping). Fourteen of the 36 piglets exhibited VF during the asphyxial insult. VF converted to asystole in four piglets prior to resuscitation. Immediately prior to resuscitation, VF occurred in 10 piglets, asystole in 19 piglets, and bradyarrhythmias in seven piglets..VF occurs frequently in this piglet model of prolonged asphyxial cardiac arrest, consistent with recent observations in pediatric prehospital cardiac arrests. VF occurred late in the asphyxial process.
• Sanders, A. B., Zalenski, R. J., White, J. D., Wears, R. L., Waeckerle, J. F., Valenzuela, T. D., Sklar, D. P., Schrop, M. A., Schriger, D. L., Sanders, A. B., Mccabe, J. B., Marx, J. A., Ling, L. J., Lewis, R. G., Lewis, L. M., Kellermann, A. L., Kelen, G. D., Hedges, J. R., Goldfrank, L. R., , Garrison, H. G., et al. (1996). Research directions in emergency medicine.. The American journal of emergency medicine, 14(7), 681-3. doi:10.1016/s0735-6757(96)90089-3
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  The goal of emergency medicine is to improve health while preventing and treating disease and illness in patients seeking emergency medical care. Improvements in emergency medical care and the delivery of this care can be achieved through credible and meaningful research efforts. Improved delivery of emergency medical care through research requires careful planning and the wise use of limited resources. To achieve this goal, emergency medicine must provide appropriate training of young investigators and attract support for their work. Promotion of multidisciplinary research teams will help the specialty fulfill its goals. The result will be the improvement of emergency medical care which will benefit not only the patients emergency physicians serve but also, ultimately, the nation's health.
• Wilcoxson, D., Sanders, A. B., Otto, C. W., Kern, K. B., Hilwig, R. W., Ewy, G. A., Eklund, D. K., & Berg, R. A. (1996). The need for ventilatory support during bystander CPR. Resuscitation, 31(1), 87. doi:10.1016/0300-9572(96)84943-4
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  Abstract Study objective: To compare CPR with chest compressions plus ventilatory support (CC+V) and chest compressions alone (CC). Design: Prospective, randomized study. Setting: Research laboratory. Interventions: After 2 minutes of ventricular fibrillation, 18 domestic swine (20 to 35 kg) were treated first with CC or CC+V for 10 minutes, then with standard advanced cardiac life support. Results: Hemodynamics, survival, and neurologic outcome were determined. All 8 swine subjected to CC+V and all 10 subjected to CC showed return of spontaneous circulation. One animal in each group died within 1 hour. Seven of 8 animals in the CC+V group survived for 24 and 48 hours, compared with 9 of 10 CC animals at 24 hours and 8 of 10 at 48 hours. All 48-hour survivors were neurologically normal. Conclusion: In this experimental model of bystander CPR, we could not detect a difference in hemodynamics, 48-hour survival, or neurologic outcome when CPR was applied with and without ventilatory support. [Berg RA, Wilcoxson D, Hilwig RW, Kern KB, Sanders AB, Otto CW, Eklund DK, Ewy GA: The need for ventilatory support during bystander CPR. Ann Emerg Med September 1995;26:342-350.]
• Zalenski, R. J., White, J. D., Wears, R. L., Waeckerle, J. F., Valenzuela, T. D., Sklar, D. P., Schriger, D. L., Sanders, A. B., Mccabe, J. B., Marx, J. A., Ling, L. J., Lewis, R. J., Lewis, L. M., Kellermann, A. L., Kelen, G. D., Hedges, J. R., Goldfrank, L. R., Garrison, H. G., Dronen, S. C., , Dart, R. C., et al. (1996). Research Directions in Emergency Medicine. Annals of Emergency Medicine, 27(3), 339-342. doi:10.1016/s0196-0644(96)70270-6
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  Abstract From the Research Directions Conference , Atlanta, January 1995. This Consensus document is being published simultaneously in Academic Emergency Medicine, American Journal of Emergency Medicine, Annals of Emergency Medicine, and Journal of Emergency Medicine. [Research Directions Conference: Research directions in emergency medicine. Ann Emerg Med March 1996;27:339-342.]
• Barnes, T. A., Sanders, A. B., Rubenfeld, R., Pepe, P. E., Mathews, M., Malinowski, M., Kaye, K., Hamill, H., Halperin, H. R., Fluck, R. R., Bishop, M. J., & Aufderheide, T. P. (1995). Clinical practice guidelines for resuscitation in acute care hospitals.. Respiratory care, 40(4), 346-59; discussion 359-63.
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  The development of the AHA Guidelines for CPR and ECC and the AARC RACH Clinical Practice Guideline should both be instrumental in improving the performance of RCPs on in-hospital resuscitation teams. The AARC and AHA are assuming important leadership roles in this movement by publishing CPGs for CPR and ECC. RCPs with ACLS training are in a prime position to assume more responsibility on resuscitation teams within acute care facilities. They should be prominent members of the resuscitation team--committed to the entire team's performance--and be actively involved in ACLS training. The first step in that process is to study the current levels of RCP competence in ACLS. Further, RCPs and health-care providers should define the goals of resuscitation in terms of long-term survival, quality of life, and years of useful life after CPR. The cost of inadequate attention to which patients should have DNR orders is a drain on the entire health-care system. Research on the impact of disease categories on CPR outcome should be used to educate physicians, nurses, and RCPs so they can help patients better understand their chances of regaining their pre-CPR quality of life. Successful CPR outcome should be carefully defined using the patient's disease category. Each patient should be individually evaluated for DNR orders. As suggested by Schwenzer, "Patients' perception of their quality of life before and after CPR should guide their and our decisions." However, we must all accept the responsibility for defining the limitations of medical technology and try to determine when CPR is futile.
• Davis, M. F., Sanders, A. B., Milander, M. M., Locke, C. J., Kern, K. B., Ewy, G. A., Davis, M. F., & Berg, R. A. (1995). Bystander cardiopulmonary resuscitation : concerns about mouth-to-mouth contact. JAMA Internal Medicine, 155(9), 938-943. doi:10.1001/archinte.1995.00430090077009
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  Background: Bystander cardiopulmonary resuscitation (CPR) is performed on only a small percentage of patients who suffer cardiac arrest. We conducted a study to elucidate attitudes toward and potential obstacles to performance of bystander CPR. Methods: Attitude survey of 975 people on the University Heart Center, University of Arizona, Tucson, mailing list. Participants were asked about their willingness to perform CPR under four conditions, with varying relationships (stranger vs relative or friend) and CPR techniques (chest compressions plus mouth-to-mouth ventilation [CC+V] vs chest compressions alone [CC]). Results: Participants rated willingness to perform CPR and concern about disease transmission. Both relationship and CPR technique affected willingness to respond. Only 15% would "definitely" provide CC+V with strangers compared with 68% who would "definitely" perform CC. Even with relatives or friends, only 74% would "definitely" provide CC+V compared with 88% who would "definitely" provide CC. Eighty-two percent of participants were at least "moderately" concerned about disease transmission. Conclusion: Concerns regarding mouth-to-mouth ventilation appear to create substantial barriers to performance of bystander CPR. Intensified educational efforts and investigations of new approaches to bystander CPR are warranted. (Arch Intern Med. 1995;155:938-943)
• Sanders, A. B. (1995). Electrocardiographic telemetry: determining its value in emergency medical services.. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 2(4), 246-7. doi:10.1111/j.1553-2712.1995.tb03216.x
• Sanders, A. B. (1995). The Maturation of Academic Emergency Medicine. Academic Emergency Medicine, 2(5), 336-337. doi:10.1111/j.1553-2712.1995.tb03239.x
• Sanders, A. B., Levine, R. J., & Lamear, W. R. (1995). Bilateral vocal cord paralysis following blunt trauma to the neck.. Annals of emergency medicine, 25(2), 253-5. doi:10.1016/s0196-0644(95)70334-9
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  Blunt trauma to the anterior neck has been known to cause upper-airway obstruction requiring emergency tracheostomy. We report the case of a 26-year-old man who sustained blunt trauma to the anterior neck in whom upper-airway obstruction developed. Although computed tomography of the neck revealed a thyroid cartilage fracture and a retropharyngeal hematoma, fiberoptic examination of the larynx identified vocal cord paralysis as the primary cause of his upper-airway obstruction. Emergency tracheostomy was performed, and the patient recovered uneventfully. A Medline search of the literature for the past 3 years failed to identify any individual case reports of bilateral vocal cord paralysis secondary to blunt anterior neck trauma.
• Sanders, A. B., Milander, M. M., Kern, K. B., Hiscok, P. S., Ewy, G. A., & Berg, R. A. (1995). Chest compression and ventilation rates during cardiopulmonary resuscitation: the effects of audible tone guidance.. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 2(8), 708-13. doi:10.1111/j.1553-2712.1995.tb03622.x
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  To determine: 1) whether chest compressions during CPR are being performed according to American Heart Association (AHA) guidelines during cardiac arrest; and 2) the effect of an audio prompt to guide chest compressions on compliance with AHA guidelines and hemodynamic parameters associated with successful resuscitation..An observational clinical report and laboratory study was conducted. A research observer responded to a convenience sample of cardiac arrests within a 300-bed hospital and counted the rate of chest compressions and ventilations during CPR. To evaluate the effect of an audio prompt on CPR, health care providers performed chest compression without guidance using a porcine cardiac arrest model for 1 minute, followed by a second minute in which audio guidance was added. Chest compression rates, arterial and venous blood pressures, end-tidal CO2 (ETCO2) levels, and coronary perfusion pressures were measured and compared for the two periods..Twelve in-hospital cardiac arrests were observed in the clinical part of the study. Only two of 12 patients had chest compressions performed within AHA guidelines. No patient had respirations performed within AHA guidelines. In the laboratory, 41 volunteers were tested, with 66% performing chest compressions outside the AHA standards for compression rate without audible tone guidance. With guided chest compressions, the mean (+/- SD) chest compression rate increased from 74 +/- 22 to 100 +/- 3/min (p < 0.01). End-tidal CO2 levels increased from 15 +/- 7 to 17 +/- 7 torr (p < 0.01). Coronary perfusion pressure increased minimally with audible tone-guided chest compressions..The majority of Basic Cardiac Life Support--certified health care professionals did not perform CPR according to AHA-recommended guidelines. The use of audible tones to guide chest compression resulted in significantly higher chest compression rates and ETCO2 levels.
• Sanders, A. B., Pepe, P. E., Durbin, C. G., Bishop, M. J., & Barnes, T. A. (1995). The development of AHA guidelines for emergency cardiac care. Respiratory Care, 40(4), 338-345.
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  In summary, the value of the ECC training programs is improving the outcome for patients in cardiac arrest. It is believed that, by giving clinicians overall guidelines to use for this emergency situation, better decisions will be made. The Guidelines are in a dynamic state of re-evaluation, and the development process for guidelines is imperfect. However, every effort has been made to look at all sides of any controversy and make decisions based on scientific evidence. In addition, recommendations are now based on the relative strength of the scientific data. The process will continue even in the absence of National Consensus meetings. Finally, the importance of transmitting the Guidelines to participants in an educationally sound program has received a great deal of emphasis. The ACLS course is now interactive and based on clinical scenarios. The emphasis is on improving the knowledge and skills of the participants who take the course rather than on certification or evaluation. The effect of these changes will be evaluated over the next several years.
• Whitley, T. W., Sanders, A. B., Mcnamara, R. M., Force, F. T., Andrew, L. B., & Andrew, J. L. (1995). The extent and effects of abuse and harassment of emergency medicine residents. The SAEM In-service Survey Task Force.. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 2(4), 293-301. doi:10.1111/j.1553-2712.1995.tb03225.x
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  To determine the extent and effects of abuse and harassment, including sexual harassment and racial or ethnic discrimination, experienced by residents in emergency medicine (EM)..The study instrument was an anonymous, self-report survey administered to a national sample of EM residents. The survey was timed to coordinate with the American Board of Emergency Medicine's annual In-Service Examination in February 1993. The residents reported whether they had experienced nine types of abuse or harassment during their residency training, the sources of these incidents, the effects on the residents, and whether they chose to file a formal complaint regarding these events..Surveys were returned by 1,774 (80%) of the 2,229 residents who sat for the examination--74.4% men and 24.6% women. Overall, 98% reported at least one occurrence of abuse or harassment, with patients being the most frequent source. More than half of the more senior residents reported having been physically hit or pushed. Other health care professionals were a frequent source of verbal abuse and sexual harassment. Women were significantly more likely than men to report unwanted sexual advances (63% vs 32%, p < 0.001), discomfort from sexual humor (66% vs 27%, p < 0.001), and unfair treatment because of gender (71% vs 15%, p < 0.001). Non-Caucasians reported a higher rate of racial or ethnic discrimination than did Caucasians (51% vs 23%, p < 0.001). As a result of these episodes, 19% of the respondents had questioned their decision to become a physician, 20% had questioned entering the specialty of EM, 11% had experienced emotional effects lasting over one month, and 11% had experienced disruption of their family lives. Only 56 (3.2%) had filed formal complaints..Residents frequently encounter abuse or harassment, particularly from patients. They also report adverse consequences from these episodes.
• Wilcoxson, D., Sanders, A. B., Otto, C. W., Kern, K. B., Hilwig, R. W., Ewy, G. A., & Berg, R. A. (1995). THE NEED FOR VENTILATORY SUPPORT DURING BYSTANDER CPR. Critical Care Medicine, 23(Supplement), A181. doi:10.1097/00003246-199501001-00313
• Wilcoxson, D., Sanders, A. B., Otto, C. W., Kern, K. B., Hilwig, R. W., Ewy, G. A., Eklund, D. K., & Berg, R. A. (1995). The need for ventilatory support during bystander CPR.. Annals of emergency medicine, 26(3), 342-50. doi:10.1016/s0196-0644(95)70084-6
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  To compare CPR with chest compressions plus ventilatory support (CC+V) and chest compressions alone (CC)..Prospective, randomized study..Research laboratory..After 2 minutes of ventricular fibrillation, 18 domestic swine (20 to 35 kg) were treated first with CC or CC+V for 10 minutes, then with standard advanced cardiac life support..Hemodynamics, survival, and neurologic outcome were determined. All 8 swine subjected to CC+V and all 10 subjected to CC showed return of spontaneous circulation. One animal in each group died within 1 hour. Seven of 8 animals in the CC+V group survived for 24 and 48 hours, compared with 9 of 10 CC animals at 24 hours and 8 of 10 at 48 hours. All 48-hour survivors were neurologically normal..In this experimental model of bystander CPR, we could not detect a difference in hemodynamics, 48-hour survival, or neurologic outcome when CPR was applied with and without ventilatory support.
• Witzke, D. B., Witzkc, D. B., Valente, J. F., Sanders, B., Sanders, A. B., Madden, C., Fritz, M., & Arthur, A. (1995). High-yield selection criteria for cranial computed tomography after acute trauma.. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 2(4), 248-53. doi:10.1111/j.1553-2712.1995.tb03217.x
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  To develop and prospectively evaluate criteria for selecting head-injured patients requiring cranial CT..A two-phased prospective observational study design was implemented at a university ED. Physicians completed a form with 51 variables for 540 patients in Phase I. Ten high-yield variables were identified and prospectively tested on 273 patients in Phase II. Prediction rule performance for identification of patients with abnormal CT scans was determined..The combined criteria had a sensitivity of 97% for CT-scan abnormalities in Phase I; sensitivity was 96% in Phase II. Negative predictive values were 97% and 94%, respectively. Prevalence of disease in Phase I was 17%; prevalence in Phase II was 16%. Had the Phase I criteria been implemented during Phase II, 43 of 273 patients (16%) would not have been scanned, including two patients with positive results who did not require operative intervention..Fifty-one clinical variables from head-injured patients were narrowed to ten of statistical significance and consistent interpretation for prospective evaluation. Patients with none of these criteria were found to be at low risk of having sustained significant head injury.
• Gallagher, E. J., Goldfrank, L. R., Anderson, G. V., Barsan, W. G., Levy, R. C., Sanders, A. B., Strange, G. R., & Trott, A. T. (1994). Current status of academic emergency medicine within academic medicine in the United States.. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 1(1), 41-6. doi:10.1111/j.1553-2712.1994.tb02798.x
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  To characterize the status of emergency medicine within U.S. academic medical centers..All accredited emergency medicine residency programs and all four-year allopathic medical schools in the United States were identified. Institutions were defined as academic medical centers based upon NIH research grant funding. These institutions were ranked using five measures of academic stature: a survey of medical school deans, a survey of internal medicine residency directors, level of research funding, characteristics of the student body, and an unweighted composite variable reflecting overall academic stature. The relationship between institutional academic stature and an empiric scale of institutional affiliation with emergency medicine was assessed..Sixty-two institutions were designated academic medical centers. These medical schools captured 90% of all NIH grant monies awarded in fiscal year 1990. Twenty-six of 87 emergency medicine residency programs (30%) were closely affiliated with one of these medical schools. Within academic medical centers, the presence of a residency or an academic department of emergency medicine was inversely associated with the medical school deans' ranking (p < 0.005), research rank (p < 0.001), and composite academic rank (p < 0.001)..The majority of emergency medicine residency programs (70%) are not closely affiliated with institutions receiving the bulk (90%) of NIH resources for research. Within the institutions receiving the majority of NIH funding, there is a quantitatively and statistically significant inverse association of institutional emergency medicine affiliation and institutional academic rank.
• Sanders, A. B., Kern, K. B., Genova, R. T., Ewy, G. A., Burress, M., & Berg, R. A. (1994). The efficacy of an ACLS training program for resuscitation from cardiac arrest in a rural community.. Annals of emergency medicine, 23(1), 56-9. doi:10.1016/s0196-0644(94)70009-5
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  To determine whether an advanced cardiac life support (ACLS) course in a rural hospital will improve resuscitation success from cardiac arrest..A retrospective case review of all patients in cardiac arrest during a 13-month period before and after the institution of an ACLS training program..Emergency department of a 42-bed rural, community hospital in a community with no prehospital advanced life support or early defibrillation..All patients in cardiac arrest were entered into the data base. Twenty-nine patients were included in the pre-ACLS period and 35 in the post-ACLS period. There were no significant differences in age, gender, initial rhythm, comorbid diseases, witnessed versus unwitnessed arrest, or total arrest time in the patients in the pre-ACLS period compared with those in the post-ACLS period..ACLS provider training..Patients in cardiac arrest who had ventricular fibrillation/tachycardia as their initial rhythm had significant improvement in resuscitation success compared with patients in ventricular fibrillation/tachycardia in the pre-ACLS period (six of 15 versus none of nine, P < .05). Out-of-hospital cardiac arrest resuscitation was more successful in the post-ACLS period than in the pre-ACLS period (five of 30 versus none of 25, P < .05). Overall, seven of 35 patients (20%) were resuscitated successfully in the post-ACLS period, with two patients surviving to hospital discharge. This was not significantly different than the two of 29 patients (7%) resuscitated in the pre-ACLS period, with one patient surviving to discharge..The institution of an ACLS-provider course in a rural community hospital was associated with improvement in initial resuscitation for patients with ventricular fibrillation/tachycardia and out-of-hospital arrest.
• Sanders, A. B., Moskop, J. C., Larkin, G. L., & Derse, A. R. (1994). The emergency physician and patient confidentiality: a review.. Annals of emergency medicine, 24(6), 1161-7. doi:10.1016/s0196-0644(94)70249-7
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  Confidentiality is a promise rooted in tradition, law, and medical ethics. Emergency physicians treat a variety of patients to whom confidentiality is of vital importance: employees, celebrities, victims of violence or disaster, minors, students, criminals, drug abusers, and patients with STDs. EDs should develop methods of ensuring confidentiality for all patients. Although confidentiality is an important principle that should be respected and guarded, it is not absolute. Various laws mandate disclosure of certain patient information; in addition, an overriding moral duty may occasionally require a breach of confidentiality. As Beauchamp and Childress noted, "the therapeutic role may sometimes have to yield to one's role as citizen and as protector of the interests of others." In general, however, circumstances requiring a breach of confidentiality are rare.
• Sanders, A. B., Otto, C. W., Kern, K. B., Hilwig, R. W., Hansen, K. K., Ewy, G. A., & Berg, R. A. (1994). High-dose epinephrine results in greater early mortality after resuscitation from prolonged cardiac arrest in pigs: A prospective, randomized study. Resuscitation, 28(2), 168. doi:10.1016/0300-9572(94)90097-3
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  To determine whether high-dose epinephrine (0.2 mg/kg) during cardiopulmonary resuscitation (CPR) results in improved outcome, compared with standard-dose epinephrine (0.02 mg/kg). A prospective, randomized, blinded study. Research laboratory of a university medical center. Thirty domestic swine were randomized to receive standard- or high-dose epinephrine during CPR after 15 mins of fibrillatory cardiac arrest. Three minutes of CPR were provided, followed by advanced cardiac life support per American Heart Association guidelines. Animals that were successfully resuscitated were supported for 2 hrs in an intensice care unit (ICU) setting, and then observed for 24 hrs. Electrocardiogram, aortic blood pressure, right atrial blood pressure, and end-tidal CO2 were monitored continuously until the intensice care period ended. Survival and neurologic outcome were determined. Return of spontaneous circulation was attained in 14 of 15 animals in each group. Four of 14 high-dose epinephrine pigs died during the ICU period after return of spontaneous circulation vs. zero of the 14 standard-dose pigs (p < .05). Six standard-dose pigs survived 24 hrs vs. four high-dose pigs. Twenty-four-hour survival rate and neurologic outcome were not significantly different. Within 10 mins of defibrillation, severe hypertension (diastolic pressure >120 mm Hg) occurred in 12 of 14 high-dose pigs vs. two of 14 standard-dose pigs (p 250 beats/min) occurred in seven of 14 high-dose pigs vs. zero of 14 standard-dose pigs (p < .01). All four high-dose epinephrine pigs that died during the ICU period experienced both severe hypertension and tachycardia immediately postresuscitation. High-dose epinephrine did not improve 24-hr survival rate or neurologic outcome. Immediately after return of spontaneous circulation, most animals in the high-dose epinephrine group exhibited a hyperadrenergic state that included severe hypertension and tachycardia. High-dose epinephrine resulted in a greater early mortality rate. (Crit Care Med 1994; 22:282–290)
• Sanders, A. B., Otto, C. W., Kern, K. B., Hilwig, R. W., Hansen, K. K., Ewy, G. A., & Berg, R. A. (1994). High-dose epinephrine results in greater early mortality after resuscitation from prolonged cardiac arrest in pigs: a prospective, randomized study.. Critical care medicine, 22(2), 282-90. doi:10.1097/00003246-199402000-00020
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  To determine whether high-dose epinephrine (0.2 mg/kg) during cardiopulmonary resuscitation (CPR) results in improved outcome, compared with standard-dose epinephrine (0.02 mg/kg)..A prospective, randomized, blinded study..Research laboratory of a university medical center..Thirty domestic swine were randomized to receive standard- or high-dose epinephrine during CPR after 15 mins of fibrillatory cardiac arrest. Three minutes of CPR were provided, followed by advanced cardiac life support per American Heart Association guidelines. Animals that were successfully resuscitated were supported for 2 hrs in an intensive care unit (ICU) setting, and then observed for 24 hrs..Electrocardiogram, aortic blood pressure, right atrial blood pressure, and end-tidal CO2 were monitored continuously until the intensive care period ended. Survival and neurologic outcome were determined. Return of spontaneous circulation was attained in 14 of 15 animals in each group. Four of 14 high-dose epinephrine pigs died during the ICU period after return of spontaneous circulation vs. zero of the 14 standard-dose pigs (p < .05). Six standard-dose pigs survived 24 hrs vs. four high-dose pigs. Twenty-four-hour survival rate and neurologic outcome were not significantly different. Within 10 mins of defibrillation, severe hypertension (diastolic pressure > 120 mmHg) occurred in 12 of 14 high-dose pigs vs. two of 14 standard-dose pigs (p < .01). Severe tachycardia (heart rate > 250 beats/min) occurred in seven of 14 high-dose pigs vs. zero of 14 standard-dose pigs (p < .01). All four high-dose epinephrine pigs that died during the ICU period experienced both severe hypertension and tachycardia immediately postresuscitation..High-dose epinephrine did not improve 24-hr survival rate or neurologic outcome. Immediately after return of spontaneous circulation, most animals in the high-dose epinephrine group exhibited a hyperadrenergic state that included severe hypertension and tachycardia. High-dose epinephrine resulted in a greater early mortality rate.
• Tellez, D., Sanders, A. B., Milander, M. M., Liu, P. H., Beyda, D. H., & Berg, R. A. (1994). Efficacy of audio-prompted rate guidance in improving resuscitator performance of cardiopulmonary resuscitation on children.. Academic Emergency Medicine, 1(1), 35-40. doi:10.1111/j.1553-2712.1994.tb00003.x
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  OBJECTIVE To evaluate the effect of audio-prompted rate guidance during chest compressions on the performance of cardiopulmonary resuscitation (CPR) on children. METHODS This 24-month prospective study occurred in the pediatric intensive care units of a university hospital and a children's hospital. Intubated children with nontraumatic cardiac arrest were eligible. After placement of an infrared capnometer between the endotracheal tube and resuscitation bag, an audiotape instructed the resuscitator to perform chest compressions at 100 per minute or 140 per minute for one minute, followed by another minute at the other rate. End-tidal carbon dioxide partial pressure (PETCO2) was recorded prior to audiotape instruction and after one minute of CPR at each rate. RESULTS Six patients, two boys and four girls, with a mean age of 15 +/- 13 months (range 2-36 months) were studied. All had asystole or pulseless electrical activity. CPR was provided for 14 +/- 9 minutes prior to institution of the study protocol. PETCO2 at 140/min was higher than at baseline (12 +/- 7 torr verus 4 +/- 3 torr, p < 0.05). There was a trend towards higher PETCO2s at 100/min compared with baseline (11 +/- 12 torr versus 4 +/- 3 torr, p = 0.08). PETCO2s did not differ at 100/min compared with 140/min. CONCLUSIONS In support of prior adult and animal investigations suggesting that basic CPRR is often performed poorly and at inappropriately slow rates, audio- prompted rate guidance during CPR in children resulted in higher PETCO2, suggesting improved CPR performance.
• Tellez, D., Sanders, A. B., P, L., Milander, M. M., Liu, P., D, T., D, B., Beyda, D., & Berg, R. A. (1994). Efficacy of audio-prompted rate guidance in improving resuscitator performance of cardiopulmonary resuscitation on children.. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 1(1), 35-40.
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  To evaluate the effect of audio-prompted rate guidance during chest compressions on the performance of cardiopulmonary resuscitation (CPR) on children..This 24-month prospective study occurred in the pediatric intensive care units of a university hospital and a children's hospital. Intubated children with nontraumatic cardiac arrest were eligible. After placement of an infrared capnometer between the endotracheal tube and resuscitation bag, an audiotape instructed the resuscitator to perform chest compressions at 100 per minute or 140 per minute for one minute, followed by another minute at the other rate. End-tidal carbon dioxide partial pressure (PETCO2) was recorded prior to audiotape instruction and after one minute of CPR at each rate..Six patients, two boys and four girls, with a mean age of 15 +/- 13 months (range 2-36 months) were studied. All had asystole or pulseless electrical activity. CPR was provided for 14 +/- 9 minutes prior to institution of the study protocol. PETCO2 at 140/min was higher than at baseline (12 +/- 7 torr verus 4 +/- 3 torr, p < 0.05). There was a trend towards higher PETCO2s at 100/min compared with baseline (11 +/- 12 torr versus 4 +/- 3 torr, p = 0.08). PETCO2s did not differ at 100/min compared with 140/min..In support of prior adult and animal investigations suggesting that basic CPRR is often performed poorly and at inappropriately slow rates, audio- prompted rate guidance during CPR in children resulted in higher PETCO2, suggesting improved CPR performance.
• Trott, A. T., Strange, G. R., Sanders, A. B., Levy, R. C., Goldfrank, L. R., Gallagher, E. J., Barsan, W. G., & Anderson, G. V. (1994). Role of emergency medicine residency programs in determining emergency medicine career choice among medical students.. Annals of emergency medicine, 23(5), 1062-7. doi:10.1016/s0196-0644(94)70104-0
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  To characterize the role of emergency medicine residency programs in determining emergency medicine career choice among medical students..Observational, cross-sectional, descriptive study. Information on student career choice was obtained through a targeted query of the National Resident Matching Program data base, simultaneously stratified by specialty and school, and adjusted for class size..All accredited emergency medicine residency programs and four-year allopathic medical schools..Fifty-two schools (42%) had a closely affiliated emergency medicine residency program, ie, one based primarily at the institution's main teaching hospital(s). This configuration was associated with a 70% increase in the median proportion of students choosing emergency medicine as a career when compared to the 73 schools with no closely affiliated emergency medicine residency (5.1% vs 3.0%, P < .0001). When institutions were stratified by overall commitment to emergency medicine, the median proportion of students choosing emergency medicine as a career was 2.9% for institutions with a minimal commitment to emergency medicine (neither an academic department of emergency medicine nor a closely affiliated emergency medicine residency), 4.1% for institutions with a moderate commitment to emergency medicine (either a department of emergency medicine or an emergency medicine residency, but not both), and 5.7% for institutions with a substantial commitment to emergency medicine (a department of emergency medicine and an emergency medicine residency) (P < .0001). When institutional commitment to emergency medicine was examined in a simple multivariate model, only the presence of an emergency medicine residency was associated independently with student career choice (P < .001)..An emergency medicine residency program that is closely affiliated with a medical school is strongly and independently associated with a quantitatively and statistically significant increase in the proportion of students from that school who choose a career in emergency medicine. These data support the proposition that, if emergency medicine is to meet national manpower shortage needs by attracting students to the specialty, it must establish residency programs within the primary teaching hospital(s) of medical schools. Such a configuration does not currently exist in the majority of schools.
• Witzke, D. B., Sanders, A. B., Fulginiti, J. V., & Bangs, K. A. (1994). Characteristics influencing career decisions of academic and nonacademic emergency physicians.. Annals of emergency medicine, 23(1), 81-7. doi:10.1016/s0196-0644(94)70013-3
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  To determine characteristics motivating physicians to choose careers in academic and nonacademic emergency medicine..A written survey of 1,017 active members of the Society for Academic Emergency medicine and of a random sample of 2,000 members of the American College of Emergency Physicians was performed. Questions were asked regarding medical school, residency, and fellowship training; the importance of specific factors in influencing career decisions; and perceived obstacles to emergency medicine research. Responses from nonfaculty and adjunct, clinical, and research faculty were compared using chi 2 analysis for discrete variables and a four-group analysis of variance for continuous variables..None..Responses were obtained from 1,203 physicians (41.3%). Those choosing academic careers were significantly more likely to complete a residency in emergency medicine or internal medicine and fellowship training in research or toxicology compared with nonacademic physicians. Nonfaculty and clinical faculty considered family obligations, leisure time, and personal income to be the most important factors influencing their career decisions; research faculty considered role models and the value of research to be most important. There was no difference in indebtedness among the groups. Finding time and funding, administrative obligations, and pressures to do clinical work were the most important obstacles to research productivity..Factors influencing career decisions can be used to plan strategies to meet the future needs of academic emergency medicine.
• Witzke, D. B., Sanders, A. B., Mcnamara, R. M., Ling, L. J., & Bangs, K. A. (1994). Substance use and alcohol abuse in emergency medicine training programs, by resident report. SAEM Residency Survey Task Force.. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 1(1), 47-53. doi:10.1111/j.1553-2712.1994.tb02799.x
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  To determine the prevalence of substance use and alcohol abuse among emergency medicine residents..The study instrument was an anonymous, self-report survey that assessed the use of 13 substances and included the CAGE questions for measuring alcohol abuse. The survey was administered to emergency medicine residents at the time of the American Board of Emergency Medicine's annual In-Service Examination..Alcohol was the substance most commonly used by emergency medicine residents for nonmedical reasons. Using the CAGE score, 4.9% of residents were classified as alcoholic and another 7.6% as suspect for alcoholism, rates similar to those for housestaff of all specialties as reported in earlier studies. Instruction related to physician impairment during training in their emergency medicine residency was reported by only 36% of the respondents..Emergency medicine residents report a low rate of illicit substance use and do not appear to misuse alcohol differently than other housestaff. Interpretation of these results must be tempered with the potential for underreporting that may occur with a voluntary self-report survey of a sensitive nature.
• Sanders, A. B., & Morley, J. E. (1993). The older person and the emergency department.. Journal of the American Geriatrics Society, 41(8), 880-2. doi:10.1111/j.1532-5415.1993.tb06189.x
• Sanders, A. B., Otto, C. W., Kern, K. B., Ewy, G. A., & Chase, P. B. (1993). Effects of graded doses of epinephrine on both noninvasive and invasive measures of myocardial perfusion and blood flow during cardiopulmonary resuscitation.. Critical care medicine, 21(3), 413-9. doi:10.1097/00003246-199303000-00020
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  Epinephrine administered during cardiopulmonary resuscitation (CPR) is known to increase aortic diastolic and myocardial perfusion pressures, while enhancing myocardial blood flow. Optimal dosing of epinephrine during CPR is less certain. Interest in high-dose epinephrine use under such circumstances is increasing. The effect of different doses of epinephrine on simultaneously measured perfusion pressures, myocardial blood flow, cardiac output, and end-tidal CO2 (PCO2) (used as an indirect measure of cardiac output during CPR) is unknown..Prospective, sequential evaluation of no epinephrine, standard dose epinephrine, and high-dose epinephrine..An experimental resuscitation laboratory..Twelve domestic swine..Myocardial perfusion pressure, myocardial blood flow, cardiac output, and end-tidal PCO2 were studied after various doses of epinephrine were administered during prolonged CPR. After 3 mins of untreated ventricular fibrillation, each animal received 5 mins of CPR without epinephrine, 5 mins of CPR after standard dose epinephrine (0.02 mg/kg), and 5 mins of CPR after high-dose epinephrine (0.2 mg/kg). Cardiac output and regional myocardial blood flow values were measured with nonradioactive, colored microspheres..Myocardial perfusion pressure (aortic diastolic minus right atrial diastolic) was significantly (p < .05) increased over baseline with high-dose epinephrine (35 +/- 8 vs. 14 +/- 4 mm Hg), but not with standard dose epinephrine (20 +/- 5 vs. 14 +/- 4 mm Hg). Epinephrine's effect on myocardial blood flow was similar, increasing after the high dose (71 +/- 21 vs. 20 +/- 5 mL/min/100 g; p > .05), but not with the standard dose (23 +/- 6 vs. 20 +/- 5 mL/min/100 g). Cardiac output decreased significantly (p < .05) after high-dose epinephrine (7 +/- 1 vs. 13 +/- 1 mL/min/kg). Mean end-tidal PCO2 levels were lower after high-dose epinephrine (15 +/- 2 vs. 20 +/- 2 mm Hg; p < .05) but not after standard dose epinephrine (19 +/- 2 vs. 20 +/- 2 mm Hg)..Standard dose epinephrine had minimal effect on myocardial perfusion pressure, myocardial blood flow, cardiac output, or end-tidal PCO2. High-dose epinephrine enhanced myocardial perfusion pressure and myocardial blood flow despite significantly decreasing cardiac output.
• Sanders, A. B., Otto, C. W., Kern, K. B., Hilwig, R. W., Ewy, G. A., & Berg, R. A. (1993). Bystander cardiopulmonary resuscitation. Is ventilation necessary?. Circulation, 88(4 Pt 1), 1907-15. doi:10.1161/01.cir.88.4.1907
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  Prompt initiation of bystander cardiopulmonary resuscitation (CPR) improves survival. Basic life support with mouth-to-mouth ventilation and chest compressions is intimidating, difficult to remember, and difficult to perform. Chest compressions alone can be easily taught, easily remembered, easily performed, adequately taught by dispatcher-delivered telephone instruction, and more readily accepted by the public. The principal objective of this study was to evaluate the need for ventilation during CPR in a clinically relevant swine model of prehospital witnessed cardiac arrest..Thirty seconds after ventricular fibrillation, swine were randomly assigned to 12 minutes of chest compressions plus mechanical ventilation (group A), chest compressions only (group B), or no CPR (group C). Standard advanced cardiac life support was then provided. Animals successfully resuscitated were supported for 2 hours in an intensive care setting, and then observed for 24 hours. All 16 swine in groups A and B were successfully resuscitated and neurologically normal at 24 hours, whereas only 2 of 8 group C animals survived for 24 hours (P < .001, Fisher's exact test). One of the 2 group C survivors was comatose and unresponsive..In this swine model of witnessed prehospital cardiac arrest, the survival and neurological outcome data establish that prompt initiation of chest compressions alone appears to be as effective as chest compressions plus ventilation and that both techniques of bystander CPR markedly improve outcome compared with no bystander CPR.
• Sanders, A. B., Otto, C. W., Kern, K. B., Hilwig, R. W., Ewy, G. A., & Berg, R. A. (1993). CARDIOPULMONARY RESUSCITATION: IS VENTILATION NECESSARY?. Critical Care Medicine, 21(Supplement), S250. doi:10.1097/00003246-199304001-00234
• Witzke, D. B., Sanders, A. B., Keim, S. M., Fulginiti, J. W., & Dyne, P. L. (1993). Beliefs and practices of emergency medicine faculty and residents regarding professional interactions with the biomedical industry.. Annals of emergency medicine, 22(10), 1576-81. doi:10.1016/s0196-0644(05)81262-4
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  To examine emergency medicine resident training and understanding of general bioethics and resident and faculty attitudes and behavior regarding professional interactions with the biomedical industry..Two companion questionnaire surveys..Annual resident in-service examination and written director survey with telephone follow-up..Emergency medicine residents and program directors..chi 2 analysis was used for questions involving relationships among variables with dichotomous or categorical response. An analysis of variance or Pearson Product Moment Correlation was calculated for questions with continuous variables..The surveys were completed by 1,385 of 1,836 (75%) residents and 80 of 81 (99%) residency directors. On average, residents receive eight hours of bioethical instruction per year but believe that they need 12 hours per year. Seventy-five percent of residents believe that company representatives sometimes cross ethical boundaries. The amount of resident understanding of bioethical concepts correlated with the number of hours of bioethics training they received. A sensitivity to bioethical conflicts index was correlated with the residents' behavior..There is wide variation in beliefs and practices regarding the interaction between emergency medicine residents and directors and the biomedical industry. Our results suggest that residents need training regarding conflicts of interest, accepted standards of practice, and dealing with potential conflicts with the biomedical industry.
• Sanders, A. B. (1992). Care of the elderly in emergency departments: conclusions and recommendations.. Annals of emergency medicine, 21(7), 830-4. doi:10.1016/s0196-0644(05)81030-3
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  Little attention is being paid to the special needs of elderly persons in emergency departments. Emergency health care professionals feel less comfortable caring for elderly than for nonelderly patients. The social and personal concerns of the elderly frequently are not addressed in ED encounters. There is a paucity of research and education in geriatric emergency medicine. Overall principles of care for elderly patients seeking emergency care have not been defined as they have for other special populations such as children. The disease-oriented model used for caring for nonelderly adult patients in EDs may not be appropriate for elderly patients. The emergency care of the elderly requires significantly more health care resources than does that of the nonelderly. Compared with nonelderly patients, elderly patients seeking emergency care are four times more likely to use ambulance services, five times more likely to be admitted to the hospital, five times more likely to be admitted to an intensive care bed, and six times more likely to receive comprehensive emergency services. Although 12% of the population is 65 years or older, this group accounted for 36% of all ambulance patient transports to EDs, 43% of all hospital ED admissions, and 48% of all critical care admissions from EDs. These problems are particularly important at this time because many hospitals and their EDs are faced with significant problems of overcrowding and inadequate resources to meet the health care needs of the communities they serve. Although the elderly are the fastest-growing segment of the population, little or no planning is ongoing to meet the emergency health care needs of the elderly in the future. The task force has provided specific recommendations for addressing these problems.
• Sanders, A. B. (1992). Care of the elderly in emergency departments: where do we stand?. Annals of emergency medicine, 21(7), 792-5. doi:10.1016/s0196-0644(05)81023-6
• Sanders, A. B., Otto, C. W., Kern, K. B., Ewy, G. A., & Berg, R. A. (1992). HIGH DOSE EPINEPHRINE DOES NOT IMPROVE SURVIVAL FROM PROLONGED CARDIAC ARREST. Critical Care Medicine, 20(Supplement), S17. doi:10.1097/00003246-199204001-00001
• Sanders, A. B., Raife, J. H., Otto, C. W., Milander, M. M., Kern, K. B., & Ewy, G. A. (1992). A Study of Chest Compression Rates During Cardiopulmonary Resuscitation in Humans: The Importance of Rate-Directed Chest Compressions. JAMA Internal Medicine, 152(1), 145-149. doi:10.1001/archinte.1992.00400130153020
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  . A prospective, cross-over trial was performed comparing two different rates of precordial compression using endtidal carbon dioxide as an indicator of the efficacy of cardiopulmonary resuscitation in 23 adult patients. A second purpose of this study was to determine the effect of audioprompted, rate-directed chest compressions on the endtidal carbon dioxide concentrations during cardiopulmonary resuscitation. Patients with cardiac arrest received external chest compressions, initially in the usual fashion without rate direction and then with rhythmic audiotones for rate direction at either 80 compressions per minute or 120 compressions per minute. Nineteen of 23 patients had higher end-tidal carbon dioxide levels at the compression rate of 120 per minute. The mean end-tidal carbon dioxide level during compressions of 120 per minute was 15.0±1.8 mm Hg, slightly but significantly higher than the mean level of 13.0±1.8 mm Hg at a compression rate of 80 per minute. However, end-tidal carbon dioxide levels increased rather dramatically when audiotones were used to guide the rate of chest compressions. Mean end-tidal carbon dioxide concentration was 8.7±1.2 mm Hg during standard cardiopulmonary resuscitation immediately before audio-prompted, rate-directed chest compression and increased to 14.0±1.3 mm Hg after the first 60 seconds of audible tones directing compressions. Using end-tidal carbon dioxide as an indicator of cardiopulmonary resuscitation efficacy, we conclude that audible rate guidance during chest compressions may improve cardiopulmonary resuscitation performance. (Arch Intern Med. 1992;152:145-149)
• Sanders, A. B., Raife, J. H., Otto, C. W., Milander, M. M., Kern, K. B., & Ewy, G. A. (1992). A Study of Chest Compression Rates During Cardiopulmonary Resuscitation in Humans: The Importance of Rate-Directed Chest Compressions. Survey of Anesthesiology, 36(5), 328. doi:10.1097/00132586-199210000-00051
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  . A prospective, cross-over trial was performed comparing two different rates of precordial compression using endtidal carbon dioxide as an indicator of the efficacy of cardiopulmonary resuscitation in 23 adult patients. A second purpose of this study was to determine the effect of audioprompted, rate-directed chest compressions on the endtidal carbon dioxide concentrations during cardiopulmonary resuscitation. Patients with cardiac arrest received external chest compressions, initially in the usual fashion without rate direction and then with rhythmic audiotones for rate direction at either 80 compressions per minute or 120 compressions per minute. Nineteen of 23 patients had higher end-tidal carbon dioxide levels at the compression rate of 120 per minute. The mean end-tidal carbon dioxide level during compressions of 120 per minute was 15.0±1.8 mm Hg, slightly but significantly higher than the mean level of 13.0±1.8 mm Hg at a compression rate of 80 per minute. However, end-tidal carbon dioxide levels increased rather dramatically when audiotones were used to guide the rate of chest compressions. Mean end-tidal carbon dioxide concentration was 8.7±1.2 mm Hg during standard cardiopulmonary resuscitation immediately before audio-prompted, rate-directed chest compression and increased to 14.0±1.3 mm Hg after the first 60 seconds of audible tones directing compressions. Using end-tidal carbon dioxide as an indicator of cardiopulmonary resuscitation efficacy, we conclude that audible rate guidance during chest compressions may improve cardiopulmonary resuscitation performance. (Arch Intern Med. 1992;152:145-149)
• Sanders, A. B., Rousseau, E. W., & Mcnamara, R. M. (1992). Geriatric emergency medicine: a survey of practicing emergency physicians.. Annals of emergency medicine, 21(7), 796-801. doi:10.1016/s0196-0644(05)81024-8
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  To evaluate the current status of clinical, educational, social, ethical, and resource issues related to the care of the elderly among practitioners of emergency medicine..A mailed survey instrument..None..Practicing emergency physicians randomly drawn from the membership list of the American College of Emergency Physicians..None..A total of 971 surveys were mailed, with 433 usable surveys among the 485 (50%) respondents. The surveyed emergency physicians anticipated a major impact on emergency department patient flow and bed availability in the hospital and ICU as the population ages. For each of seven clinical presentations (abdominal pain, altered mental status, chest pain, dizziness/vertigo, fever without a source, headache, multisystem trauma), 45% or more of the emergency physicians have more difficulty in the management of older compared with younger patients. Most respondents reported that each of these presentations required more time and resources for older patients. The majority believed research, the availability of continuing medical education, and time spent during residency training regarding geriatric emergency medicine was inadequate..Practicing emergency physicians are uncomfortable with elderly patients, and this may reflect the inadequacies of training, research, and continuing education in geriatric emergency medicine.
• Schropp, M. A., Sanders, A. B., Rousseau, E. W., & Jones, J. S. (1992). Geriatric training in emergency medicine residency programs.. Annals of emergency medicine, 21(7), 825-9. doi:10.1016/s0196-0644(05)81029-7
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  The health care needs of the elderly population are significantly different from those of younger patients and require special knowledge and skills on the part of emergency physicians. The purpose of this study was to identify the nature and extent of geriatric training currently provided to emergency medicine residents..Self-administered survey distributed to residency directors of the 85 accredited emergency medicine residency programs in the United States..The survey consisted of 17 questions focusing on residency directors' views about teaching and research of geriatric emergency care..Survey information was obtained from 85 (100%) emergency medicine residency programs. Forty percent (34 of 85) of respondents believed the teaching of geriatric emergency care was inadequate; 44 programs (52%) plan to increase the number of didactic hours devoted to geriatrics (mean increase of 5.9 hours). The five geriatric topics most frequently taught included acute dementia, atypical presentation of illness, common complaints in the elderly, geriatric trauma, and ethical issues. Sixty-five percent believed ongoing national research efforts regarding geriatric emergency medicine were insufficient; 21 programs (25%) had faculty involved in geriatric studies. Most respondents reported that growing numbers of elderly will have a major impact on all areas of patient care in the near future..Although geriatric emergency care is becoming an integral part of the emergency medicine residency program, there may be a need for better focused and more intensive training.
• Singal, B. M., Sanders, A. B., Rousseau, E. W., Mcnamara, R. M., Hogan, T. M., Hedges, J. R., & Bernstein, E. (1992). Geriatric patient emergency visits. Part II: Perceptions of visits by geriatric and younger patients.. Annals of emergency medicine, 21(7), 808-13. doi:10.1016/s0196-0644(05)81026-1
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  To compare group perceptions of reasons for emergency department care, ED use patterns, and the effect of illness on self-care ability for elderly and younger adult patients..Patient survey..Six geographically distinct US hospital EDs..From each site, a stratified sample (approximately 7:3) of elderly (65 years and older) and nonelderly (21 to 64 years old) control ED patients treated during the same time period was contacted..Three hundred ninety-nine elderly patients and 172 adult controls were interviewed using a structured survey instrument. Groups were compared using chi 2 analysis and the Mann-Whitney U test..Both the elderly and the control patients (49% versus 38%) commonly stated that the most important reason for coming to the ED was because they were "too sick to wait for an office visit." Of patients with a regular physician, both groups often were referred to the ED by their primary care provider (35% versus 26%). While the elderly had more visits to their primary care provider (3.3 versus 2.9 visits; P less than .00001), there was no difference in the number of ED visits (1.5 versus 1.6 visits) during the preceding six months. Of those released from the ED, more elderly noted deterioration in their ability to care for themselves as a result of their illness (21% versus 11%; P less than .03)..The elderly use the ED for reasons similar to those for younger adults. Often they feel too ill to wait for an office visit or are referred in by their primary care provider. Elderly patients more commonly have difficulty with self care after release home, and emergency physicians must plan accordingly.
• Singal, B. M., Sanders, A. B., Rousseau, E. W., Mcnamara, R. M., Hogan, T. M., Hedges, J. R., & Berstein, E. (1992). Geriatric patient emergency visits. Part I: Comparison of visits by geriatric and younger patients.. Annals of emergency medicine, 21(7), 802-7. doi:10.1016/s0196-0644(05)81025-x
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  To describe emergency department use by the elderly, to define problems associated with emergency care of the elderly, and to compare these results with those for younger adult patients..Retrospective, controlled chart review..Six geographically distinct US hospital EDs..From each site, a stratified sample (approximately 7:3) of elderly (65 years or older) and nonelderly (21 to 64 years old) control patients treated during the same time period was used..Standardized review of ED records and billing charges. Comparisons of elderly and control patient groups using chi 2 analysis and Mann-Whitney U test (alpha = 0.05)..Four hundred eighteen elderly patients and 175 nonelderly controls were entered into the study. The elderly were more likely to arrive by ambulance (35% versus 11%; P less than .00001). More elderly than controls presented with conditions of either high or intermediate urgency (78% versus 61%; P less than .0003). The elderly more frequently presented with comorbid diseases (94% versus 63%; P less than .00001). Other findings for the elderly included a longer mean stay in the ED (185 versus 155 minutes; P less than .003), higher laboratory (78% versus 53%; P less than .00001) and radiology (77% versus 52%; P less than .00001) test rates, higher mean overall care charges ($471 versus $344; P less than .00001), and an admission rate (47% versus 19%; P less than .00001) twice that of younger adults..Resource use and charges associated with emergency care are higher for the elderly than for younger patients. Increases in emergency resources and personnel or improvement in efficiency will be needed to maintain emergency care at present levels as the US population continues to grow and age.
• Sklar, D. P., Sanders, A. B., Keim, S. M., & Adams, J. G. (1992). Emergency physicians and the biomedical industry.. Annals of emergency medicine, 21(5), 556-8. doi:10.1016/s0196-0644(05)82524-7
• Spaite, D. W., Smith, R., & Sanders, A. B. (1992). Erratum: Meeting the goals of academia: Characteristics of emergency medicine faculty academic work styles (J Emerg Med (1988) 6 (435-437)). Annals of Emergency Medicine, 21(6), 763. doi:10.1016/s0196-0644(05)82801-x
• Strange, G. R., Sanders, A. B., & Chen, E. H. (1992). Use of emergency departments by elderly patients: projections from a multicenter data base.. Annals of emergency medicine, 21(7), 819-24. doi:10.1016/s0196-0644(05)81028-5
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  To assess the use of emergency medical care by the elderly in the United States, including emergency department visits, level of ED care required, ambulance services, and hospital admission rate..A multicenter computerized data base of 70 hospitals in 25 states..A retrospective review of elderly patients seeking ED care and comparison of elderly and nonelderly patients. The data were then used to estimate the use of emergency medical services nationally..Fifteen percent of the 1,193,743 ED visits were made by patients 65 years or older. Thirty-two percent of elderly patients seen in EDs were admitted to the hospital, compared with 7.5% of nonelderly patients. Seven percent of elderly patients were admitted to ICUs, compared with 1% of nonelderly patients. Thirty percent of elderly patients seeking emergency care used ambulance transports compared with 8% of nonelderly. It is estimated that 13,693,400 elderly patients were seen in EDs in 1990, with more than 4 million patients admitted to hospitals. Compared with the nonelderly, the elderly are 4.4 times more likely to use ambulance transport, 5.6 times more likely to be admitted to the hospital, 5.5 times more likely to be admitted to an intensive care bed, and 6.1 times more likely to be classified as a comprehensive ED level of service. In our sample, 36% of all patients arriving by ambulance to the ED, 43% of all ED admissions, and 48% of all intensive care admissions were geriatric patients..With the rapid growth of the size of the elderly population, it is important that we assess the emergency medical resources needed to care for the geriatric population.
• Witzke, D. B., Sanders, A. B., & Fulginiti, J. V. (1992). Factors influencing resident career choices in emergency medicine.. Annals of emergency medicine, 21(1), 47-52. doi:10.1016/s0196-0644(05)82236-x
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  To assess the attitudes of residents in emergency medicine regarding a career in academics..A 22-item questionnaire was administered to residents in conjunction with the yearly American Board of Emergency Medicine inservice examination. Demographic information and factors influencing career intent were elicited. Respondents were classified by intent on a career in emergency medicine. A three-way analysis of variance was used to address group differences for eight specific factors impacting on career decision. Chi-square analysis was used to address questions involving relationships among variables with dichotomous or categorical responses..The survey was distributed to 1,654 residents, and 1,238 (75%) completed the questionnaire. Motivating factors demonstrating significant differences between those residents planning an academic career and those not interested in academe were a desire to do research, desire to teach, desire to make a contribution to medicine, and exposure to role models, with less emphasis on the need for free time for other interests and less concern regarding practice location. More than 80% of those not going into academic emergency medicine believed they were adequately exposed to research in residency compared with 65% of those intent on a career in academe (P less than .01). Research in medical school, residency, and authorship of a research paper were significantly more prevalent for those residents desiring a career in academe (P less than .01). Twenty-six percent of residents responded that their role models for research were less than adequate. Seventeen percent of residents intend to take fellowship training. The most popular fields for fellowships were toxicology (25%), emergency medical services (21%), pediatrics (15%), and research (9%)..The results of this survey address attitudes among residents toward a career in academic emergency medicine. Factors such as motivation, role models, and exposure to research may help academicians plan strategies to meet the future needs of academic emergency medicine.
• Sanders, A. B. (1991). Interpretation of the Electrocardiogram, ed 2, KM Jones, GM Ochs. Appleton & Lange, Dallas (1990), 293 pages, $29.95. Annals of Emergency Medicine, 20(2), 220. doi:10.1016/s0196-0644(05)81247-8
• Sanders, A. B., Nelson, J., Kern, K. B., Federiuk, C. S., & Ewy, G. A. (1991). The effect of bicarbonate on resuscitation from cardiac arrest.. Annals of emergency medicine, 20(11), 1173-7. doi:10.1016/s0196-0644(05)81465-9
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  This study attempted to determine the effect of bicarbonate administration on resuscitation in a porcine model of prolonged cardiac arrest..After instrumentation, 26 swine were subjected to ventricular fibrillation for 15 minutes (16 animals) or 20 minutes (ten animals) with no resuscitative efforts..Resuscitation attempts with open-chest cardiac massage and epinephrine were used in all animals after the arrest period. The experimental group was given sodium bicarbonate (3 mEq/kg), and the control group received 3% saline (5 mL/kg) at the initiation of cardiac massage..Resuscitation success, hemodynamics, and arterial and mixed venous gases were compared in the bicarbonate and hypertonic saline-treated groups..There was no difference in resuscitation rates between bicarbonate and nonbicarbonate-treated swine. After 15 minutes of ventricular fibrillation, six of eight bicarbonate-treated swine were resuscitated successfully compared with five of eight hypertonic saline-treated animals. None of the five bicarbonate-treated or five hypertonic saline-treated swine that underwent 20 minutes of ventricular fibrillation were resuscitated. The arterial and mixed venous pH values were significantly different in the bicarbonate-treated animals from values in the control group. There was no difference in systolic or diastolic blood pressures or myocardial perfusion pressure between the bicarbonate and hypertonic saline-treated animals..Despite correlation of arterial and venous acidemia, the use of sodium bicarbonate did not improve resuscitation from prolonged cardiac arrest.
• Sanders, A. B., Raife, J., Otto, C. W., Milander, M. M., Kern, K. B., & Ewy, G. A. (1991). Negative predictive value of end-tidal carbon dioxide for the resuscitation of patients in cardiac arrest. Journal of the American College of Cardiology, 17(2), A180. doi:10.1016/0735-1097(91)91685-8
• Sklar, D. P., Schmidt, T. A., Sanders, A. B., Knopp, R. K., Keim, S. M., Kalbfleisch, N., Iserson, K. V., Hedges, J. R., Green, C., Goldfrank, L. R., Franaszek, J. B., Derse, A. R., & Adams, J. G. (1991). The HIV-infected emergency health care professional. SAEM Ethics Committee.. Annals of emergency medicine, 20(9), 1036-40. doi:10.1016/s0196-0644(05)82991-9
• Smith, J., Sklar, D. P., Sanders, A. B., Moskop, J. C., Mitchell, J. M., Malone, K., Knopp, R. K., Derse, A. R., & Allison, E. J. (1991). American College of Emergency Physicians Ethics Manual.. Annals of emergency medicine, 20(10), 1153-62. doi:10.1016/s0196-0644(05)81399-x
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  Ethical concerns are a major part of the clinical practice of emergency medicine. The emergency physician must make hard choices, not only with regard to the scientific/technical aspects but also with regard to the moral aspects of caring for emergency patients. By the nature of the specialty, emergency physicians face ethical dilemmas often requiring prompt decisions with limited information. This manual identifies important moral principles and values in emergency medicine. The underlying assumption is that a knowledge of moral principles and ethical values helps the emergency physician make responsible moral choices. Neither the scientific nor the moral aspects of clinical decision making can be reduced to simple formulas. Nevertheless, decisions must be made. Emergency physicians should, therefore, be cognizant of the ethical principles that are important for emergency medicine, understand the process of ethical reasoning, and be capable of making rational moral decisions based on a stable framework of values.
• Tacker, W. A., Sanders, A. B., Nelson, J. R., Kern, K. B., Janas, W., Ewy, G. A., Badylak, S. F., & Babbs, C. F. (1991). Limitations of open-chest cardiac massage after prolonged, untreated cardiac arrest in dogs.. Annals of emergency medicine, 20(7), 761-7. doi:10.1016/s0196-0644(05)80838-8
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  Open-chest cardiac massage is an effective method of resuscitation if instituted within 15 minutes of normothermic cardiac arrest that has failed to respond to ongoing closed-chest CPR efforts. The usefulness of invasive forms of CPR after various periods of untreated cardiac arrest is less certain. This study was performed to determine the effectiveness of open-chest resuscitation after prolonged periods of untreated cardiac arrest..Prospective, controlled laboratory investigation using an animal model of cardiac arrest. Open-chest cardiac massage initially was compared to standard closed-chest compression CPR. The efficacy of open-chest CPR then was evaluated after ten and 40 minutes of untreated ventricular fibrillation..Twenty mongrel dogs (24 +/- 1 kg)..After 20 minutes of untreated ventricular fibrillation, open-chest resuscitation was significantly better than closed-chest efforts for the production of coronary perfusion pressure (58 +/- 14 vs 2 +/- 1 mm Hg; P less than .05) and initial resuscitation success (five of five vs one of five; P less than .03). Open-chest cardiac massage was equally effective for initial resuscitation if begun after ten or 20 minutes of untreated ventricular fibrillation (five of five vs five of five), but if untreated ventricular fibrillation continued for 40 minutes prior to instituting open-chest massage, no resuscitation benefit was found (none of five; P less than .005). There were marked differences in 24-hour survival depending on the length of time untreated cardiac arrest continued prior to instituting open-chest resuscitation efforts. After 20 minutes of ventricular fibrillation, initial resuscitation was successful with open-chest massage, but long-term survival was poor..Open-chest cardiac massage did not produce long-term survival if untreated cardiac arrest persisted for 20 or more minutes prior to invasive resuscitation efforts.
• Trott, A. T., Strange, G. R., Sanders, A. B., & Hamilton, G. C. (1991). An Approach to Clinical Problem Solving. Pediatric Emergency Care, 7(5), 324. doi:10.1097/00006565-199110000-00079
• Wiggins, D., Schlager, D., Sanders, A. B., & Boren, W. (1991). Ultrasound for the detection of foreign bodies.. Annals of emergency medicine, 20(2), 189-91. doi:10.1016/s0196-0644(05)81220-x
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  To determine the ability of an emergency physician to detect a variety of foreign bodies in an experimental model using a portable ultrasound device..Ten pieces of beef were sliced into cubes approximately 6 cm on each side. Six different groups of foreign bodies were examined: gravel, cactus spine, glass, metal, wood, and plastic. An independent observer placed the objects in a random fashion into the beef cubes. One hundred twenty observations were made using sets of ten beef cubes at a time. Five foreign bodies were placed into each set of ten beef cubes..A blinded emergency physician used a portable ultrasound with a 7.5-MHz transducer to determine the presence or absence of a foreign body in each cube..Ultrasound detected 59 of 60 foreign bodies, including all cubes of meat embedded with gravel, cactus spine, plastic, metal, and wood. Glass was detected nine of ten times. Of the 60 cubes of meat with no foreign bodies, one false-positive was recorded. This yielded sensitivity, specificity, positive predictive value, and negative predictive value of 98%. Positive determinations by ultrasound were significantly greater in the meat cubes with foreign bodies compared with the control group with no foreign bodies (P less than .001 by chi 2). Although the subset of glass foreign bodies had one false-positive and one false-negative, it was not significantly different in comparison with the other groups (P greater than .05 by chi 2)..Ultrasound has promise as a diagnostic tool for the detection of a variety of foreign bodies. Further clinical studies using ultrasound for the detection of foreign bodies are warranted.
• Sanders, A. B. (1990). Emergency medicine faculty shortage--the medical school perspective.. Annals of emergency medicine, 19(7), 826-7. doi:10.1016/s0196-0644(05)81713-5
• Sanders, A. B., Otto, C. W., Kern, K. B., Fonken, S., & Ewy, G. A. (1990). The role of bicarbonate and fluid loading in improving resuscitation from prolonged cardiac arrest with rapid manual chest compression CPR.. Annals of emergency medicine, 19(1), 1-7. doi:10.1016/s0196-0644(05)82129-8
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  Rapid manual chest compression (120 compressions/min) CPR has been shown to improve hemodynamics and survival when compared with standard CPR (60 compressions/min) in a canine model of prolonged cardiac arrest. The study showing improved survival with rapid manual CPR empirically included treatment with bicarbonate and initial fluid loading. To determine the role of bicarbonate and fluid loading in the success of rapid manual chest compression CPR, 31 mongrel dogs were studied. After instrumentation with micromanometer-tipped catheters to measure aortic and right atrial pressures, the animals were assigned sequentially to three treatment groups. Group A underwent rapid manual chest compressions at 120 compressions/min, bicarbonate treatment, and initial fluid loading. Group B underwent rapid manual compressions at 120 compressions/min without bicarbonate or fluid loading. Group C underwent standard CPR at 80 compressions/min with bicarbonate and fluid loading. After 30 minutes of ventricular fibrillation, defibrillation was attempted. Seven of 11 dogs in group A survived 24 hours. None of the animals in group B resuscitated or survived. Three of the ten dogs in group C survived 24 hours. Survival with rapid manual CPR without bicarbonate and initial fluid loading was significantly less than when these interventions were used (P less than .01). To examine the separate contribution of bicarbonate and fluid therapy, two additional groups of animals were studied. Fourteen animals (group D) received rapid manual CPR with bicarbonate therapy, and 12 (group E) received rapid manual CPR with fluid loading only.(ABSTRACT TRUNCATED AT 250 WORDS)
• Sanders, A. B., Otto, C. W., Milander, M. M., Kern, K. B., & Ewy, G. A. (1990). End-Tidal Carbon Dioxide Monitoring During Cardiopulmonary Resuscitation. A Prognostic Indicator for Survival. Survey of Anesthesiology, 34(5), 340. doi:10.1097/00132586-199010000-00062
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  The effectiveness of ongoing cardiopulmonary resuscitation efforts is difficult to evaluate. Recent studies suggest that carbon dioxide excretion may be a useful noninvasive indicator of resuscitation from cardiac arrest. A prospective clinical study was done to determine whether end-tidal carbon dioxide monitoring during cardiopulmonary resuscitation could be used as a prognostic indicator of resuscitation and survival. Thirty-five cardiac arrests in 34 patients were monitored with capnometry during cardiopulmonary resuscitation during a 1-year period. Nine patients who were successfully resuscitated had higher average end-tidal carbon dioxide partial pressures during cardiopulmonary resuscitation than 26 patients who could not be resuscitated (15±4 vs 7±5 mm Hg). The 3 patients who survived to leave the hospital had a higher average end-tidal carbon dioxide partial pressure than the 32 nonsurvivors (17 ± 6 vs 8 ± 5 mm Hg). All 9 patients who were successfully resuscitated had an average end-tidal carbon dioxide partial pressure of 10 mm Hg or greater. No patient with an average end-tidal carbon dioxide partial pressure of less than 10 mm Hg was resuscitated. Data from this prospective clinical trial indicate that findings from end-tidal carbon dioxide monitoring during cardiopulmonary resuscitation are correlated with resuscitation from and survival of cardiac arrest. ( JAMA . 1989;262:1347-1351)
• Sanders, A. B., Otto, C. W., Milander, M. M., Kern, K. B., & Ewy, G. A. (1990). End-Tidal Pco2 During Cardiopulmonary Resuscitation-Reply. JAMA, 263(6), 815-815. doi:10.1001/jama.1990.03440060054031
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  In Reply.— We appreciate the comments of Weil et al and Dr Yetiv regarding our recent article. Weil et al noted the potential importance of the continuous measurement of end-tidal carbon dioxide tension (P ET CO 2 ) during cardiopulmonary resuscitation (CPR). We agree and note that P ET CO 2 was continuously monitored in all 35 patients reported. Trends in P ET CO 2 were reported in Fig 2 of the article. Patients who were not successfully resuscitated showed a steady and significant decline in P ET CO 2 , while successfully resuscitated patients showed an increase in P ET CO 2 that was not statistically significant. We caution the reader, however, about making conclusions that our experimental methodology was not designed to test. We demonstrated a strong clinical association between P ET CO 2 during ongoing CPR efforts and resuscitation and survival from cardiac arrest. It remains to be demonstrated
• Sanders, A. B., Rossum, A. C., Nelson, J., Kern, K. B., & Ewy, G. A. (1990). Improved left ventricular blood flow with increased rates of external chest compressions. Journal of the American College of Cardiology, 15(2), A215. doi:10.1016/0735-1097(90)92578-p
• Tackerd, W. A., Tacker, W. A., Sloan, D., Sanders, A. B., Nelson, J., Kern, K. B., Janas, W., Garewal, H. S., & Ewy, G. A. (1990). Depletion of myocardial adenosine triphosphate during prolonged untreated ventricular fibrillation: effect on defibrillation success.. Resuscitation, 20(3), 221-9. doi:10.1016/0300-9572(90)90005-y
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  We studied left ventricular endomyocardial adenosine triphosphate levels in 13 large mongrel dogs before and during ventricular fibrillation induced cardiac arrest to assess whether myocardial adenosine triphosphate content could predict successful cardiopulmonary resuscitation. Endomyocardial biopsies were performed during sinus rhythm (control), after 15 min of ventricular fibrillation or 10 min of ventricular fibrillation and 5 min of open chest cardiopulmonary resuscitation, after 20 min of ventricular fibrillation and 10 min of open chest cardiopulmonary resuscitation and after 40 min ventricular fibrillation and 15-20 min open chest cardiopulmonary resuscitation. Myocardial adenosine triphosphate was measured utilizing a bioluminescence method adapted for use with endomyocardial biopsies and normalized to protein content. Left ventricular endomyocardial adenosine triphosphate content fell significantly over time from a control level of 8.88 +/- 0.9 micrograms/mg protein to 5.73 +/- 0.5 micrograms/mg protein at 15 min of cardiac arrest, to 3.4 +/- 0.4 micrograms/mg protein after 30 min of cardiac arrest and to 1.98 +/- 0.3 micrograms/mg protein after 60 min of cardiac arrest (P less than 0.001). Adenosine triphosphate levels were significantly different between animals that received 10 min of ventricular fibrillation and successful open chest cardiopulmonary resuscitation and those that received 40 min of ventricular fibrillation and unsuccessful open chest cardiopulmonary resuscitation (4.35 +/- 0.48 vs. 2.11 +/- 0.43 micrograms/mg protein; P less than 0.025).(ABSTRACT TRUNCATED AT 250 WORDS)
• Sanders, A. B. (1989). Capnometry in emergency medicine.. Annals of emergency medicine, 18(12), 1287-90. doi:10.1016/s0196-0644(89)80260-4
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  Capnometers measure carbon dioxide (CO2) in expired air and provide clinicians with a noninvasive measure of systemic metabolism, circulation, and ventilation. If two of these systems are held relatively constant, changes in CO2 excretion will reflect the third. CO2 measurement has been advocated as a method of ensuring endotracheal intubation. Because the air in the esophagus has very low levels of CO2, the use of capnometers may help prevent unrecognized esophageal intubation in prehospital and emergency department settings. In patients with normal perfusion and ventilation, end-tidal CO2 measurements closely reflect alveolar PCO2. Capnometry may decrease the need for frequent arterial blood gas measurements. A sudden change in end-tidal CO2 measurement may indicate decreased lung perfusion and an early shock state. Thus, capnometry may be useful to monitor critical patients in the ED. In addition, capnometry has potential usefulness as a noninvasive indicator of the efficacy of ongoing CPR efforts. End-tidal CO2 has been shown to correlate with cardiac output, perfusion pressures, and successful resuscitation in experimental models of cardiac arrest. Further clinical studies are needed to define the role of capnometry in emergency medicine.
• Sanders, A. B., Otto, C. W., Milander, M. M., Kern, K. B., & Ewy, G. A. (1989). End-Tidal Carbon Dioxide Monitoring During Cardiopulmonary Resuscitation: A Prognostic Indicator for Survival. JAMA, 262(10), 1347-1351. doi:10.1001/jama.1989.03430100081033
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  The effectiveness of ongoing cardiopulmonary resuscitation efforts is difficult to evaluate. Recent studies suggest that carbon dioxide excretion may be a useful noninvasive indicator of resuscitation from cardiac arrest. A prospective clinical study was done to determine whether end-tidal carbon dioxide monitoring during cardiopulmonary resuscitation could be used as a prognostic indicator of resuscitation and survival. Thirty-five cardiac arrests in 34 patients were monitored with capnometry during cardiopulmonary resuscitation during a 1-year period. Nine patients who were successfully resuscitated had higher average end-tidal carbon dioxide partial pressures during cardiopulmonary resuscitation than 26 patients who could not be resuscitated (15±4 vs 7±5 mm Hg). The 3 patients who survived to leave the hospital had a higher average end-tidal carbon dioxide partial pressure than the 32 nonsurvivors (17 ± 6 vs 8 ± 5 mm Hg). All 9 patients who were successfully resuscitated had an average end-tidal carbon dioxide partial pressure of 10 mm Hg or greater. No patient with an average end-tidal carbon dioxide partial pressure of less than 10 mm Hg was resuscitated. Data from this prospective clinical trial indicate that findings from end-tidal carbon dioxide monitoring during cardiopulmonary resuscitation are correlated with resuscitation from and survival of cardiac arrest. ( JAMA . 1989;262:1347-1351)
• Tacker, W. A., Sanders, A. B., Kern, K. B., Ewy, G. A., Elchisak, M. A., & Badylak, S. F. (1989). Plasma catecholamines and resuscitation from prolonged cardiac arrest.. Critical care medicine, 17(8), 786-91. doi:10.1097/00003246-198908000-00013
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  Plasma catecholamine levels rise markedly with cardiac arrest and attempted resuscitation. We examined whether epinephrine (EPI) or norepinephrine (NE) plasma concentrations could predict resuscitation outcome. In nine mongrel dogs, EPI and NE levels were drawn before cardiac arrest and after 8 and 14 min of cardiac arrest and CPR. Intravenous EPI (1 mg) was given 1 min before the last plasma level was drawn. Catecholamines were quantitated by high-performance liquid chromatography with triple-electrode coulometric electrochemical detection. Plasma catecholamines increased significantly with cardiac arrest, EPI levels increased from a control level of 15.9 +/- 3.0 to 396.0 +/- 63.3 pmol/ml after 8 min of cardiac arrest (p less than .05), and NE levels similarly increased from 4.4 +/- 1.7 to 66.5 +/- 12.0 pmol/ml (p less than .01). Neither the absolute catecholamine plasma concentration nor the response to cardiac arrest of the endogenous catecholamine concentrations could predict outcome, but catecholamine responses to exogenous EPI did correlate with outcome. Animals which were subsequently resuscitated had a greater increase in the plasma EPI concentrations after exogenous EPI than animals that were not resuscitated, a 53-fold vs. a 23-fold increase (p less than .05). Successfully resuscitated animals also had increased NE levels after exogenous EPI, while unsuccessfully resuscitated animals had either no change or a decrease (p less than .02). Successfully resuscitated animals had an increase in coronary perfusion pressure (p less than .01) in response to exogenous EPI, in contrast to those that were not resuscitated. This suggests that the exogenous administration of EPI during prolonged CPR is beneficial despite markedly elevated endogenous catecholamine levels.
• Voorhees, W. D., Tacker, W. A., Sanders, A. B., Kern, K. B., Ewy, G. A., & Babbs, C. F. (1989). Changes in expired end-tidal carbon dioxide during cardiopulmonary resuscitation in dogs: a prognostic guide for resuscitation efforts.. Journal of the American College of Cardiology, 13(5), 1184-9. doi:10.1016/0735-1097(89)90282-9
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  Expired end-tidal carbon dioxide (PCO2) measurements made during cardiopulmonary resuscitation have correlated with cardiac output and coronary perfusion pressure when wide ranges of blood flow are included. The utility of such measurements for predicting resuscitation outcome during the low flow state associated with closed chest cardiopulmonary resuscitation remains uncertain. Expired end-tidal PCO2 and coronary perfusion pressures were measured in 15 mongrel dogs undergoing 15 min of closed chest cardiopulmonary resuscitation after a 3 min period of untreated ventricular fibrillation. In six successfully resuscitated dogs, the mean expired end-tidal PCO2 was significantly higher than that in nine nonresuscitated dogs only after 14 min of cardiopulmonary resuscitation (6.2 +/- 1.2 versus 3.4 +/- 0.8 mm Hg; p less than 0.05). No differences in expired end-tidal PCO2 values were found at 2, 7 or 12 min of cardiopulmonary resuscitation. A significant decline in end-tidal PCO2 levels during the resuscitation effort was seen in the nonresuscitated group (from 6.3 +/- 0.8 to 3.4 +/- 0.8 mm Hg; p less than 0.05); the successfully resuscitated group had constant PCO2 levels throughout the 15 min of cardiac arrest (from 6.8 +/- 1.1 to 6.2 +/- 1.2 mm Hg). Changes in expired PCO2 levels during cardiopulmonary resuscitation may be a useful noninvasive predictor of successful resuscitation and survival from cardiac arrest.
• Sanders, A. B. (1988). Myocardial salvage: pharmacologic treatment.. Emergency Medicine Clinics of North America, 6(2), 361-372. doi:10.1016/s0733-8627(20)30565-4
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  Summary We have attempted to review the role of pharmacologic agents in the treatment of patients with acute myocardial infarction for the purposes of limiting infarct size. At this time, the beta-blocking agents and nitroglycerin have been the most extensively studied in clinical trials and should be part of our overall pharmacologic approach to patients with acute myocardial infarction. Treatment, however, needs to be individualized, depending on the resources available within one's hospital and community. The early treatment of patients with acute myocardial infarction is undergoing a revolution. Whereas a decade ago we were satisfied with simply monitoring patients for malignant arrhythmias, now we are aggressively attempting to limit infarct size and reperfuse myocardium. In all these proposed treatments for myocardial salvage, time is a crucial element. Therefore, emergency physicians and paramedics become a vital link to begin appropriate treatment leading to myocardial salvage and reperfusion. We must begin to think of all patients with symptoms of acute myocardial infarction as candidates for aggressive attempts at myocardial salvage. These attempts will only take place with well-coordinated, multidiscipline efforts involving cardiologists, cardiothoracic surgeons, emergency physicians, paramedics, and critical care teams. Our challenge over the next few years will be to develop efficient systems so that all patients with acute myocardial infarction can receive optimal care.
• Sanders, A. B. (1988). Session 2: Thrombolysis for acute myocardial infarction. Annals of Emergency Medicine, 17(11), 1166-1167. doi:10.1016/s0196-0644(88)80062-3
• Sanders, A. B., & Dart, R. C. (1988). Oxygen free radicals and myocardial reperfusion injury.. Annals of emergency medicine, 17(1), 53-8. doi:10.1016/s0196-0644(88)80504-3
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  Diseases involving tissue reperfusion following ischemia are gaining significance in emergency medicine. The significance of reperfusion injury and the probable role of oxygen-derived free radicals has been described in many tissues, particularly the heart. During myocardial reperfusion a burst of oxygen-derived free radicals overwhelms normal cellular defenses. These radicals may have several detrimental effects. They can oxidize lipids, leading to membrane dysfunction. They can also alter nucleic and other proteins. Cellular dysfunction and death may ensue. Prevention of oxygen-derived free radical injury appears possible and may be feasible for several disease processes, including myocardial reperfusion after infarction.
• Sanders, A. B., Kern, K. B., & Ewy, G. A. (1988). Open chest massage for resuscitation from cardiac arrest.. Resuscitation, 16(3), 153-4. doi:10.1016/0300-9572(88)90041-x
• Sanders, A. B., Rogers, J. N., Perrault, P., Otto, C. W., Kern, K. B., & Ewy, G. A. (1988). Acid-base balance in a canine model of cardiac arrest.. Annals of emergency medicine, 17(7), 667-71. doi:10.1016/s0196-0644(88)80606-1
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  Our study was performed to determine the pattern of arterial, venous, and cerebral spinal fluid (CSF) acidosis in a canine model of cardiac arrest and resuscitation; and the effect of bicarbonate treatment on arterial, venous, and CSF acidosis. Animals were instrumented to sample arterial blood, mixed venous blood, and CSF through a cisternal catheter. Following six minutes of ventricular fibrillation, manual CPR efforts were begun and continued for 30 minutes of cardiac arrest. Arterial, mixed venous, and CS fluids were sampled at baseline, six, 12, 18, 24, 27, and 30 minutes. Ten experimental dogs received sodium bicarbonate (2 mEq/kg) at 20 minutes of cardiac arrest, while ten animals in the control group received no alkali treatment. The experimental group showed a significantly higher arterial (7.79 +/- 0.20 vs 7.46 +/- 0.16 at 30 minutes) and venous pH (7.34 +/- 0.12 vs 7.19 +/- 0.10 at 24 minutes) following bicarbonate administration. This higher pH occurred despite a concomitant increase in arterial (31 +/- 10 vs 19 +/- 9 mm Hg at 27 minutes; 31 +/- 9 vs 10 +/- 8 at 30 minutes) and venous (104 +/- 30 vs 63 +/- 10 mm Hg at 24 minutes) pCO2. CSF analysis showed a gradually worsening acidosis. However, CSF pH (7.12 +/- 0.14 vs 7.16 +/- 0.23 at 30 minutes) and pCO2 were not significantly changed by the administration of bicarbonate.
• Spaite, D. W., Smith, R., Sanders, A. B., & Criss, E. A. (1988). Allocation of time in three academic specialties.. The Journal of emergency medicine, 6(5), 435-7. doi:10.1016/0736-4679(88)90025-x
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  A survey was done to: 1) characterize the allocation and distribution of time by tenure track emergency physicians, and 2) compare the time distribution of emergency physicians to two other academic disciplines. All emergency medicine residency programs were surveyed by telephone to determine if faculty were eligible for tenure and if tenure was available, how many hours per week were spent on clinical duties, research, and administrative tasks. Similar information was compiled from cardiology and orthopedic surgery faculty at the same universities. Data from the survey revealed that a tenure track assistant professor spends 23 hours (46%) working clinical shifts in the emergency department; 11 hours (20%) doing research and 18 hours (34%) in administrative tasks. In contrast, cardiologists spend significantly more time in clinical duties (32 hours) and research (18 hours). However, cardiologists spend significantly less time in administrative duties (10 hours). Data for orthopedic surgeons show a similar pattern. Distributions within each academic discipline were also analyzed and a significant difference in research time was found between four tenure track emergency medicine programs and the other eighteen. Data from this survey may help academic emergency physicians evaluate how they are allocating their time in comparison to other busy clinical specialties.
• Tacker, W. A., Sanders, A. B., Nelson, J., Kern, K. B., Janas, T., Ewy, G. A., Badylak, S. F., & Babbs, C. F. (1988). THE EFFECTIVENESS OF OPEN CHEST CARDIAC MASSAGE AFTER PROLONGED UNTREATED CARDIAC ARREST. Critical Care Medicine, 16(4), 446. doi:10.1097/00003246-198804000-00173
• Sanders, A. B., Kern, K. B., & Ewy, G. A. (1987). Open-chest cardiac massage after closed-chest compression in a canine model: when to intervene.. Resuscitation, 15(1), 51-7. doi:10.1016/0300-9572(87)90097-9
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  Open-chest cardiac massage appears beneficial in improving hemodynamics during resuscitation efforts and in improving resuscitation success. The time between cardiac arrest and the initiation of open-chest cardiac massage is crucial. It would appear that if initiation of open chest cardiac massage is delayed for more than 20 min from the onset of cardiac arrest, little or no successful outcome can be expected. Further techniques for assessing the adequacy of closed-chest compression CPR are needed. Such techniques would allow early identification of ineffective resuscitation efforts and provide the opportunity for early change to other, presumably more effective, techniques.
• Sanders, A. B., Kern, K. B., Ewy, G. A., & Bragg, S. (1987). Neurologic benefits from the use of early cardiopulmonary resuscitation.. Annals of emergency medicine, 16(2), 142-6. doi:10.1016/s0196-0644(87)80002-1
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  The efficacy of bystander CPR in resuscitation from cardiac arrest when defibrillation is available within five to six minutes has been questioned. Epidemiologic studies from different cities have shown conflicting results. We conducted a study to determine the effect of early CPR versus no CPR on resuscitability, 24-hour survival, and neurologic deficit in an animal model of cardiac arrest. Twenty-two mongrel dogs were subjected to five minutes of electrically induced ventricular fibrillation. In 11 dogs, closed-chest massage and ventilation with room air was begun immediately and was continued for five minutes. The other 11 dogs received no CPR. At five minutes defibrillation was attempted and advanced cardiac life support (ACLS) protocols were followed until the animal was resuscitated or died. No statistical difference in resuscitability or 24-hour survival between the two groups was demonstrated. Eight of 11 "early CPR" animals were resuscitated and survived 24 hours; six of 11 "no CPR" dogs were resuscitated, and five lived for 24 hours. A significant difference was demonstrated by the Student t test in neurologic deficit and ease of resuscitation. "Early CPR" dogs had no neurologic deficit, while "no CPR" dogs had a 41% deficit (P less than .01). "Early CPR" dogs were resuscitated in significantly less time once ACLS was started (29 versus 317 seconds), and required less electrical energy (100 versus 560 J), fewer countershocks (1.3 versus 4.0), and less epinephrine (0.1 versus 1.7 mg) than did "no CPR" animals. In this animal model of cardiac arrest, early CPR was shown to be beneficial to neurologic function and ease of resuscitation, even when ACLS was provided within five minutes.
• Sanders, A. B., Otto, C. W., Fahmy, H., Ewy, G. A., Brillman, J. A., & Bragg, S. (1987). Comparison of epinephrine and phenylephrine for resuscitation and neurologic outcome of cardiac arrest in dogs.. Annals of emergency medicine, 16(1), 11-7. doi:10.1016/s0196-0644(87)80278-0
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  A study was done comparing resuscitability and 24-hour neurologic outcome in fibrillating dogs that were treated with either phenylephrine (a primary alpha agonist) or epinephrine. Ventricular fibrillation was induced electrically in 18 dogs. After three minutes, standard CPR was instituted using a mechanical resuscitator. Dogs were given phenylephrine or epinephrine at nine minutes and defibrillation was attempted at 12 minutes. Dogs underwent hemodynamic monitoring and pharmacologic support, if necessary, for an additional 90 minutes. At four, eight, 12, and 24 hours, a standard neurologic examination was performed and deficit scores were assigned by an observer blinded to the drug given. Fourteen of the 18 dogs were resuscitated. There were no statistically significant differences in the epinephrine- or phenylephrine-treated groups with regard to number of animals resuscitated, time and interventions required for resuscitation, initial cardiac rhythm post resuscitation, or occurrence of ventricular fibrillation during resuscitation. No differences were found in arterial, central venous, or myocardial perfusion pressures during CPR. Phenylephrine-treated dogs tended to have higher mean pressures in the critical care period (15 to 30 minutes), although this was not significant. Total neurologic deficit scores were 127.8 +/- 83.8 for the phenylephrine-treated group and 129.4 +/- 87.4 for the epinephrine group. No significant differences were found in the level of consciousness, cranial nerve function, motor skills, or general behavior scores. We conclude that there is no difference in neurologic or cardiovascular outcome when phenylephrine is compared to epinephrine in a canine model of cardiac arrest and cardiopulmonary resuscitation.
• Meislin, H. W., Steckl, P., Sanders, A. B., Raife, J., Meislin, H. W., Criss, E. A., & Allen, D. (1986). An analysis of medical care at mass gatherings.. Annals of emergency medicine, 15(5), 515-9. doi:10.1016/s0196-0644(86)80984-2
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  Emergency medical care at public gatherings is haphazard at best and dangerous at worst. The Arizona chapter of the American College of Emergency Physicians, through the Chapter Grant Program, studied the level of medical care provided at public gatherings in order to develop guidelines for emergency medical care at mass gatherings. The study consisted of a survey of medical care at 15 facilities providing events for the public. The results of these surveys showed a wide variation of medical care provided at mass events. Of the 490 medical encounters reviewed, 52.2% were within the realm of care of paramedics, but not basic emergency medical technicians. The most common injuries/illnesses were lacerations, sprains, headaches, and syncope. Problems noted included poor documentation and record keeping of medical encounters, a tendency for prehospital care personnel to make medical evaluations without transport or medical control, and variability of care provided. Based on this survey and a literature review, guidelines for medical care at mass gatherings in Arizona were determined using an objective-oriented approach. It is our position that event organizers have the responsibility of ensuring the availability of emergency medical services for spectators and participants. We recommend that state chapters or National ACEP evaluate the role of emergency medical care at mass gatherings.
• Sanders, A. B., Raessler, K. L., Otto, C. W., Kern, K. B., Gilston, A., Geehr, E. C., Ewy, G. A., & Auerbach, P. S. (1986). More on open-chest cardiac massage after cardiac arrest.. The New England journal of medicine, 315(15), 968-9. doi:10.1056/nejm198610093151513
• Voorhees, W. D., Tacker, W. A., Sanders, A. B., Kern, K. B., Ewy, G. A., & Babbs, C. F. (1986). Neurologic outcome following successful cardiopulmonary resuscitation in dogs.. Resuscitation, 14(3), 149-55. doi:10.1016/0300-9572(86)90119-x
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  Successful cardiopulmonary resuscitation necessitates that both myocardial and central nervous system function be restored with minimal long-term damage. Recent resuscitation research has emphasized minimizing neurologic damage during and after cardiopulmonary resuscitation. However, whether neurologic damage is a major cause of death or morbidity following successful cardiopulmonary resuscitation is unknown. This study examined the role of neurologic injury as a cause for morbidity and mortality following cardiopulmonary resuscitation, and if parameters used successfully during resuscitation for assessing the potential for myocardial salvage, could also be used to predict neurologic outcome. Eighty-eight mongrel dogs underwent 3 min of untreated ventricular fibrillation and either 15 or 17 min of cardiopulmonary resuscitation. Twenty-four hour survivors were evaluated with a neurologic deficit scoring system. Thirty-one percent of these animals were never resuscitated. Twenty-eight percent were resuscitated, but expired prior to 24 h. Approximately half of those who expired after resuscitation died from apparent neurologic sequellae. Forty-one percent of the 88 animals survived for 24 h. Two-thirds of these survivors were completely neurologically normal, while one-third were neurologically impaired. Hemodynamic parameters useful in assessing cardiovascular prognosis were not helpful in predicting neurologic outcome. Hence, although the majority of resuscitated animals did not suffer neurologic damage, up to one-third did exhibit neurologic impairment following resuscitation. Neurologic injury is also a major contributor to early death following successful resuscitation. Hemodynamic parameters of cardiovascular recovery do not predict neurologic outcome after prolonged cardiopulmonary resuscitation.
• Witzke, D. B., Sanders, A. B., & Criss, E. A. (1986). Core content survey of undergraduate education in emergency medicine.. Annals of emergency medicine, 15(1), 6-11. doi:10.1016/s0196-0644(86)80478-4
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  One hundred forty-one medical schools were surveyed to determine the emergency medicine core content topics and skills being taught in the curricula. Responses were obtained from 96 schools through two mailings and a telephone followup. Most topics surveyed were offered in the vast majority of medical schools (greater than 92%) with the exception of emergency medical services (offered in 79% of schools). Emergency medicine topics were a required part of the curriculum in a much smaller percentage of schools. No subtopics in toxicology, ophthalmologic emergencies, or emergency medical services were required in more than 30% of schools. The survey showed a similar pattern of these skills being offered in most schools, but required in a smaller number. For example, while C-spine immobilization is taught in 90% of schools, it is required in only 46%. Educators must consider a coherent, interdisciplinary knowledge base and skills list for their medical school curricula.
• Witzke, D. B., Sanders, A. B., Levitt, M. A., & Criss, E. A. (1986). Survey of undergraduate emergency medical education in the United States.. Annals of emergency medicine, 15(1), 1-5. doi:10.1016/s0196-0644(86)80477-2
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  To determine the status of undergraduate education in emergency medicine, questionnaires were sent to 141 medical schools. Of the 135 schools responding, 15.2% require emergency medicine courses in the fourth year (mean, 164 hours); 11.9% require these courses (average, 84 hours) in the third year. Emergency medicine is offered in 21.8% of second-year and 37.9% of first-year curriculums. Training in cardiopulmonary resuscitation is offered in 96% of the schools responding, and certification is required in 53%. Training in advanced cardiac life support is offered in 73% of schools, with 23% requiring it for graduation. Training in advanced trauma life support is offered in 17.2% of schools. Osteopathic schools require more time for emergency medicine in the clinical years but less time in formal lectures. Schools with a residency program in emergency medicine more frequently offer emergency medicine in the preclinical years. This survey provides some basic data on the status of undergraduate emergency medicine education in medical school curriculums, and it encourages medical educators to review the undergraduate curriculum to ensure that students receive adequate exposure to the essentials of emergency medicine.
• Witzke, D. B., Stair, T. O., Sanders, A. B., & Burdick, W. P. (1986). An analysis of Part II of the National Board of Medical Examiners Test with regard to questions in emergency medicine.. Annals of emergency medicine, 15(1), 12-5. doi:10.1016/s0196-0644(86)80479-6
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  We conducted a study to determine the number of items and successful response rate to questions specific to emergency medicine on the National Board of Medical Examiners Test, Part II (NBME-II). The 1979 and 1983 NBME-II examinations were reviewed by a subcommittee of the Society of Teachers of Emergency Medicine. Items pertaining directly to the core content knowledge base were selected and classified by core content topic and NBME subspecialty. Overall, 14.7% of the 892 items on the 1983 examination pertained to emergency medicine. The successful response rate was 73.3% for the emergency medicine questions. When looked at by sub-specialty categories, the percentage of items pertaining to emergency medicine varied from 1.3% in obstetrics/gynecology to 27.2% of the items in surgery. On the 1979 examination, 13.8% of the questions pertained to emergency medicine, with a successful response rate of 67.1%. Analysis of the data by core content topic showed that some areas (orientation to emergency medicine, ophthalmologic diseases, environmental emergencies, and behavioral emergencies) had two items or fewer on both examinations. Other topics, such as trauma, showed a consistent pattern of questions on both examinations. Our study emphasizes the difficulty of attempting to test competency in the clinical knowledge base of medicine within the artificiality of knowledge base departmental boundaries.
• Meislin, H. W., Sanders, A. B., Meislin, H. W., & Kaback, K. (1985). MAST Suits-Reply. JAMA, 254(8), 1035-1035. doi:10.1001/jama.1985.03360080045020
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  In Reply.— We acknowledge the studies of Harman et al and Kron et al 1,2 indicating that elevation of intra-abdominal pressure impairs renal function. Inflation of the abdominal portion of the MAST suit is likely to increase intra-abdominal pressure, but this does not necessarily create the same situation as that experienced by the patients of Kron et al, 2 in whom increased intra-abdominal pressure resulted from postoperative complications, such as bleeding. Animal studies of renal compromise from MAST inflation have yielded variable results. Several human studies have suggested that any renal compromise is not clinically significant. Begin et al 3 reported no cases of renal failure in 47 patients with MAST use. Wayne and MacDonald 4 found a renal failure rate in hypotensive patients treated with MAST of 1%, a rate comparable with that of other studies where MAST was not employed. Despite the infrequency of renal failure with MAST
• Sanders, A. B., Kern, K. B., & Ewy, G. A. (1985). Time limitations for open-chest cardiopulmonary resuscitation from cardiac arrest.. Critical care medicine, 13(11), 897-8. doi:10.1097/00003246-198511000-00008
• Sanders, A. B., Kern, K. B., Ewy, G. A., Bragg, S., & Atlas, M. (1985). Expired PCO2 as a prognostic indicator of successful resuscitation from cardiac arrest.. Annals of emergency medicine, 14(10), 948-52. doi:10.1016/s0196-0644(85)80235-3
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  We performed a study to determine if the measurement of expired PCO2 during CPR for cardiac arrest could be used as a prognostic indicator of successful resuscitation. Twelve mongrel dogs were fibrillated electrically, and external chest massage and assisted ventilation were applied for 15 minutes. Expired PCO2 and aortic and right atrial pressures were monitored each minute of arrest. Coronary perfusion pressure (CPP) was calculated by subtracting the right atrial from the aortic diastolic pressure. Half the dogs received high-force chest compression (80 lb) and half received low-force chest compression (40 lb). The six dogs that received high-force compression were resuscitated successfully. The expired PCO2 was significantly higher in the successfully resuscitated dogs (expired PCO2 = 9.6 +/- 3.2 mm Hg) when compared to those dogs that died (expired PCO2 = 3.2 +/- 1.1 mm Hg, P less than .01). Expired PCO2 was highly correlated (r = 0.91, P less than .01) with the CPPs. The measurement of expired PCO2 during attempted CPR may be useful as a noninvasive indicator of CPP and adequate technique. Further studies on the use of this technique as an assessment criterion are warranted.
• Sanders, A. B., Kern, K. B., Ewy, G. A., Bragg, S., & Atlas, M. (1985). Expired PCO2 as an index of coronary perfusion pressure.. The American journal of emergency medicine, 3(2), 147-9. doi:10.1016/0735-6757(85)90039-7
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  Presently, there is no reliable noninvasive method of assessing the adequacy of cardiopulmonary resuscitation (CPR). Studies of animals have shown that during prolonged arrest the coronary perfusion pressure (CPP) is correlated with successful resuscitation. During previous studies it appeared that expired PCO2 correlated with CPP. To investigate this relationship, eight mongrel dogs (mean weight, 22.7 +/- 5.8 kg) were anesthetized with pentobarbital. Catheters were placed in the thoracic aorta and right atrium of each dog. Each animal was electrically fibrillated, and CPR was started using mechanical resuscitator. The PCO2 was determined at end expiration using a Hewlett Packard 47210A Capnometer with the electrode attached to the endotracheal tube. After 10, 15, 20, or 25 minutes of ventricular fibrillation and closed-chest massage, a thoracotomy was performed, and internal massage was begun. Coronary perfusion pressure was calculated at least each minute and correlated with the PCO2 values. A correlation coefficient of 0.78 was calculated based on 368 data points for eight dogs (P less than 0.01). The results of this study indicate that expired PCO2 is positively correlated with CPP in the canine model of CPR. Inasmuch as CPP correlates with survival in prolonged CPR, the noninvasive measurement of PCO2 may be a useful method of assessing the adequacy of CPR.
• Sanders, A. B., Kern, K. B., Ewy, G. A., Bragg, S., & Atlas, M. (1985). Importance of the duration of inadequate coronary perfusion pressure on resuscitation from cardiac arrest.. Journal of the American College of Cardiology, 6(1), 113-8. doi:10.1016/s0735-1097(85)80261-8
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  The effect of the duration of inadequate coronary perfusion pressure on resuscitation from cardiac arrest was examined in 32 mongrel dogs with a mean weight of 22 +/- 5 kg. In all dogs, the heart was electrically fibrillated and closed chest compression with assisted ventilation was performed for 15 minutes. At this time, all dogs had an inadequate coronary perfusion pressure (mean 7 +/- 9 mm Hg) and were randomized to a control group (group 1) with continued closed chest compression or to one of the three groups with open chest cardiac massage. These three groups differed only in the duration of continued closed chest compression before initiation of open chest massage (15, 20 and 25 minutes, respectively, in groups 2, 3 and 4). The control group (group 1) had no significant increase in coronary perfusion pressure, and only one of the eight dogs could be resuscitated. The three groups with open chest cardiac massage had a significant increase in coronary perfusion pressure (from 5 +/- 9 to 51 +/- 26 mm Hg, p less than 0.05), but the rate of successful resuscitation depended on the duration of inadequate coronary perfusion pressure before cardiac open chest massage. In group 2, six of eight dogs were resuscitated (p less than 0.05 compared with the control group); in group 3, three of eight dogs were resuscitated and in group 4 none of the eight dogs was resuscitated. The resuscitation rate was significantly (p less than 0.05) greater in group 2 than in group 4. These findings indicate that techniques that improve coronary perfusion pressure during cardiopulmonary resuscitation must be applied before extensive myocardial cellular dysfunction occurs if the probability of successful resuscitation is to be improved.
• Sanders, A. B., Ogle, M., & Ewy, G. A. (1985). Coronary perfusion pressure during cardiopulmonary resuscitation.. The American journal of emergency medicine, 3(1), 11-4. doi:10.1016/0735-6757(85)90003-8
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  Currently, there is no way to measure the effectiveness of cardiopulmonary resuscitation in humans. The literature suggests that minimum aortic diastolic and estimated coronary perfusion pressures during cardiopulmonary resuscitation (CPR) in the animal model correlate with higher resuscitation rates. Six patients were studied during CPR to determine the arterial diastolic and estimated coronary perfusion pressures (arterial minus right atrial diastolic pressures). Mean arterial pressures were 27/11 mm Hg, central venous pressures were 32/10 mm Hg, and the mean estimated coronary perfusion pressure was only 1 mm Hg. None of the six patients survived. This study demonstrates that the techniques of measuring hemodynamic values during CPR is practical. Poor estimated coronary perfusion pressures were obtained from the six patients studied. This study should be extended to include a large number of patients to determine whether these hemodynamic parameters can be used as prognostic indicators of successful resuscitation in humans.
• Sanders, A. B., Otto, C. W., Fahmy, H., Ewy, G. A., Brillman, J. A., & Bragg, S. (1985). Outcome of resuscitation from fibrillatory arrest using epinephrine and phenylephrine in dogs.. Critical care medicine, 13(11), 912-3. doi:10.1097/00003246-198511000-00013
• Seifert, S. A., Sanders, A. B., & Kobernick, M. E. (1985). Emergency department management of the sexual assault victim.. The Journal of emergency medicine, 2(3), 205-14. doi:10.1016/0736-4679(85)90398-1
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  The optimal management of the sexual assault victim involves a multidisciplinary effort on the part of all legal, police, medical, and support personnel who interface in the emergency department. History, general physical examination, and pelvic examination are performed methodically, keeping in mind that the primary goal is to tend to the patient's medical needs. The gathering of evidence proceeds simultaneously with the physical examination. Evidence to be obtained and techniques are reviewed. Treatment entails attention to physical injuries, potential venereal disease and pregnancy, and psychiatric intervention. Management of the male rape victim or child victim of sexual abuse requires special attention to the peculiarities of those problems.
• Witzke, D. B., Stair, T. O., Sanders, A. B., & Burdick, W. P. (1985). Analysis of the national board examination with regard to questions in emergency medicine. Annals of Emergency Medicine, 14(5), 490. doi:10.1016/s0196-0644(85)80325-5
• Gurley, H. T., Morkovin, V., Jayne, H. A., Stair, T. O., Sanders, A. B., Morkovin, V., Jayne, H. A., Gurley, H. T., & Brown, C. G. (1984). Curriculum for undergraduate education in emergency medicine.. Journal of medical education, 59(5), 427-9. doi:10.1097/00001888-198405000-00010
• Meislin, H. W., Sanders, A. B., Meislin, H. W., & Ewy, G. A. (1984). The physiology of cardiopulmonary resuscitation. An update.. JAMA, 252(23), 3283-3286. doi:10.1001/jama.1984.03350230043031
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  WHILE great strides have been made in the care of patients who suffer cardiac arrest, there is much room for improvement. The basic technique of cardiopulmonary resuscitation (CPR) has changed little since Kouwenhoven and colleagues 1 introduced it in 1960. The present standard was set by a committee of experts at the National Conference on Cardiopulmonary Resuscitation and Emergency Cardiac Care in 1973 2 and updated in 1979. 3 How successful has this technique been? Recent studies have shown that patients suffering in-hospital cardiac arrest have a 14% to 24% chance of being discharged alive. 4,5 This past year, Bedell and associates 4 reviewed 294 consecutive patients who underwent CPR in a university hospital in Boston. Only 41 patients were discharged alive; many who died, however, had serious underlying medical problems. DeBard 5 reviewed 1,073 cases of patients undergoing CPR in a community hospital in Dayton, Ohio. Fifty-six percent of patients
• Meislin, H. W., Sanders, A. B., Meislin, H. W., & Kaback, K. R. (1984). MAST Suit Update. JAMA, 252(18), 2598-2603. doi:10.1001/jama.1984.03350180052030
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  THE MAST suit has become a standard component of the prehospitalization armamentarium.1Other terms in the medical literature that have been used to refer to essentially the same device include medical antishock trousers, military antishock trousers, antishock garments, G-suits, anti-shock air pants, external counterpressure devices, pneumatic trousers, counterpressure suits, circumferential pneumatic compression devices, and pneumatic antishock garments. MAST suit is the most popular term; it is often used to refer to all of the aforementioned devices, although it is a trade name. This article critiques the antishock trousers made by all manufacturers. When we allude to MAST suits we are not singling out one manufacturer but referring to the generic product. The MAST suit consists of a pair of trousers with three inflatable bladders held in place by Velcro fasteners or zippers. It resembles a large blood pressure cuff tailored into a pair of pants. The suit consists of
• Sanders, A. B. (1984). Emergency medicine education.. Journal of medical education, 59(7), 612. doi:10.1097/00001888-198407000-00016
• Sanders, A. B. (1984). Human subjects research in emergency medicine. Annals of Emergency Medicine, 13(12), 1170-1171. doi:10.1016/s0196-0644(84)80360-1
• Sanders, A. B. (1984). The roles of methoxamine and norepinephrine in electromechanical dissociation.. Annals of emergency medicine, 13(9 Pt 2), 835-9. doi:10.1016/s0196-0644(84)80454-0
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  Electromechanical dissociation (EMD) in patients in cardiac arrest is associated with a poor prognosis. Pressor agents, particularly alpha-agonists, have proven to be useful in resuscitation from asphyxial and fibrillatory arrest in the animal model. Beta-agonists, such as isoproterenol, have not been shown to improve the resuscitation rate. The standard pressor used in all forms of cardiac arrest is epinephrine. The key question that must be considered is whether methoxamine or norepinephrine is superior to epinephrine in resuscitating patients in cardiac arrest. Methoxamine is a pure alpha 1 agonist causing vasoconstriction and increased peripheral vascular resistance. Norepinephrine and epinephrine demonstrate activity at alpha 1, alpha 2, beta 1, and beta 2 receptor sites. Does alpha 2 and beta activity help or hinder resuscitation? Beta activity on the myocardium will increase oxygen consumption (inotropic and chronotropic effects), may predispose to arrhythmias, and will shunt blood from the endocardium to the epicardium. On the other hand, there is evidence that beta agonists increase coronary and cerebral blood flow. Outcome studies have shown methoxamine to be comparable to epinephrine in resuscitation from asphyxial arrest. One study demonstrated methoxamine's superiority in raising the aortic diastolic pressure and resuscitating animals from ventricular fibrillation. No significant advantage of norepinephrine use is evident in the literature. Controlled experiments in the animal model and in human patients must be done to determine whether methoxamine or epinephrine is superior in resuscitation from EMD and other forms of cardiac arrest.
• Sanders, A. B., & Ewy, G. A. (1984). Open-chest CPR: not yet.. The American journal of emergency medicine, 2(6), 566-7. doi:10.1016/0735-6757(84)90087-1
• Sanders, A. B., & Hitt, J. M. (1984). Prehospital care telemetry--how essential?. The Journal of emergency medicine, 1(5), 417-20. doi:10.1016/0736-4679(84)90204-x
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  The telemeterized ECG, once a necessary and important part of prehospital care, may now be an unnecessary, expensive luxury. Paramedic training now produces a professional capable of diagnosing ECG rhythms as accurately as emergency physicians. ECG telemetry may, however, have utility for esprit de corps, training, evaluation, and supervision of new or less trained paramedics. Recommendations for establishing or renewing community telemetry systems are made.
• Sanders, A. B., & Kobernick, M. E. (1984). Educating internists in emergency medicine.. The Western journal of medicine, 141(4), 534-7.
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  The education of internists in emergency medicine needs to be thoughtfully planned by those involved in their education. Objectives for their emergency medicine rotation include the recognition and initial treatment of true medical and surgical emergencies, clinical experience with and knowledge of common acute primary care problems, the ability to handle several patients with problems having different degrees of urgency, effective use of consultants in the follow-up and management of difficult patients and a knowledge of and clinical experience with the prehospital care system. A curriculum should be designed to give the resident a core of didactic material in addition to supervised clinical experience. The rotation should be evaluated by both residents and faculty from internal medicine and emergency medicine to determine if it is accomplishing the objectives set forth.
• Sanders, A. B., Kern, K. B., Ewy, G. A., Bailey, L., & Atlas, M. (1984). Improved resuscitation from cardiac arrest with open-chest massage.. Annals of emergency medicine, 13(9 Pt 1), 672-5. doi:10.1016/s0196-0644(84)80723-4
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  A study was done to assess the effect of open-chest massage on resuscitation from cardiac arrest. Ten mongrel dogs weighing 20.3 +/- 3.2 kg were fibrillated electrically. Cardiopulmonary resuscitation (CPR) was initiated and continued for 15 minutes. Half the dogs with coronary perfusion pressures less than 30 mm Hg underwent thoracotomy and internal cardiac massage for three minutes. Closed-chest massage was continued with the other dogs. All dogs were defibrillated at 19 minutes, and resuscitation was determined at 20 minutes after defibrillation. None of the dogs in the closed-chest massage group was resuscitated successfully. Four of the five dogs that underwent open cardiac massage were resuscitated. Significant differences in aortic pressures and coronary perfusion pressures were noted for the first two minutes of open-chest massage (P less than .05). The results of this study indicate that resuscitation may be improved using open-chest massage when closed-chest massage fails to produce an adequate coronary perfusion pressure.
• Sanders, A. B., Levitt, M. A., & Kaback, K. (1984). Transient focal abnormalities with confusion: a case of thrombotic thrombocytopenic purpura.. Annals of emergency medicine, 13(2), 126-9. doi:10.1016/s0196-0644(84)80576-4
• Taft, T. V., Sanders, A. B., & Ewy, G. A. (1984). Prognostic and therapeutic importance of the aortic diastolic pressure in resuscitation from cardiac arrest.. Critical care medicine, 12(10), 871-3. doi:10.1097/00003246-198410000-00007
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  A study was done to determine if 12 dogs could be resuscitated from 30 min of ventricular fibrillation if aortic diastolic blood pressure was maintained above 30 mm Hg by administration of epinephrine and, in 6 cases, saline solution during cardiopulmonary resuscitation (CPR). Of the 12 dogs seven were resuscitated successfully. The survivors received 3.4 +/- 1.7 mg of epinephrine, whereas the nonsurvivors received 11.1 +/- 2.1 mg of epinephrine. The aortic diastolic blood pressure was significantly higher (p less than .05) in the survivors at 12, 18, 24, and 30 min of ventricular fibrillation. In all nonsurvivors, it was impossible to maintain diastolic pressure above 30 mm Hg even with large doses of epinephrine and saline. Maintenance of an adequate diastolic blood pressure during CPR appears important for survival.
• Taft, T. V., Sanders, A. B., & Ewy, G. A. (1984). Reliability of femoral artery sampling during cardiopulmonary resuscitation.. Annals of emergency medicine, 13(9 Pt 1), 680-3. doi:10.1016/s0196-0644(84)80725-8
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  A study was undertaken to determine whether femoral arterial blood gas (ABG) content adequately reflects central oxygenation and acid base status during cardiopulmonary resuscitation (CPR) from fibrillatory arrest in the canine model. Six dogs were fibrillated electrically. After 3 minutes, CPR was begun. ABG samples were taken simultaneously from femoral and thoracic aortic catheters at 0, 3, 8, 13, 23, and 28 minutes of ventricular fibrillation. Pair analysis revealed a statistically significant difference between aortic and femoral PO2 values throughout the duration of external chest compression and assisted ventilation (P less than .05). The aortic PO2 was 12% more than the femoral PO2. There was no difference in pH and PCO2 between the femoral and aortic blood gas samples. The lower femoral PO2 observed may be the result of poorer blood flow to the lower half of the body. It was concluded that femoral PO2 underestimates aortic PO2 during external chest compression and assisted ventilation in the canine model.
• Taft, T. V., Sanders, A. B., & Ewy, G. A. (1984). Resuscitation and arterial blood gas abnormalities during prolonged cardiopulmonary resuscitation.. Annals of emergency medicine, 13(9 Pt 1), 676-9. doi:10.1016/s0196-0644(84)80724-6
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  A study was undertaken to determine the pattern of arterial blood gas (ABG) concentration in the canine model undergoing prolonged cardiopulmonary resuscitation (CPR) from fibrillatory arrest, and to determine the importance of acid base abnormalities in predicting resuscitation. Ventricular fibrillation was induced electrically in 12 dogs. CPR was begun at 3 minutes and continued for 27 minutes, at which time the dogs were defibrillated. ABG samples were taken at 0, 8, 18, and 28 minutes of ventricular fibrillation. Seven of the 12 dogs were resuscitated successfully. There was no difference in pH, PCO2, or PO2 between the survivors and nonsurvivors at any of the points measured. A pattern of pH and PCO2 abnormalities was noted in each dog over 30 minutes. Each developed a respiratory alkalosis that peaked at 8 minutes. During the next 22 minutes the pH gradually declined. This combination of respiratory alkalosis and metabolic acidosis resulted in normalization of the pH at about 18 minutes of fibrillation. We concluded that when adequate ventilation is provided in the canine model undergoing CPR, significant arterial acidemia does not occur for at least 18 minutes. Further, acid base abnormalities did not correlate with successful resuscitation.
• Witzke, D. B., Sanders, A. B., Levitt, L., & Criss, E. A. (1984). Survey of undergraduate medical education in the United States. Annals of Emergency Medicine, 13(5), 381-382. doi:10.1016/s0196-0644(84)80130-4
• Meislin, H. W., Sanders, A. B., & Meislin, H. W. (1983). Effect of altitude change on MAST suit pressure.. Annals of emergency medicine, 12(3), 140-4. doi:10.1016/s0196-0644(83)80552-6
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  Transport of patients involving changes in altitude has become commonplace in the treatment of trauma patients. Often these patients are treated with medical antishock trouser (MAST) suits initially and during transport. The effects of altitude changes on the pressures generated in MAST suits were systematically investigated. Jobst Standard Antishock Air Pants were applied to the lower half of a Resusci-Anne dummy and inflated to 30 mm Hg of pressure. In a simulation of patient transport, the inflated MAST suit and dummy were placed in a helicopter and ascended from 2,500 feet to 9,500 feet. Pressures increased to 84, 87, and 87 mm Hg in three separate trials. Intermittent MAST suit pressure readings at 1,000-foot increments in altitude showed a positive linear relationship. Three descending trials, in which the MAST suit was inflated to 60 mm Hg at 9,500 feet and the helicopter descended to 2,500 feet, were also done. Pressures dropped to 7, 8.5, and 8 mm Hg in the three trials. A positive second order relationship between MAST suit pressure and altitude was noted for the descending trials. It was concluded that MAST suit pressure is a function of altitude. Emergency medicine personnel should be aware of this, and should monitor patients accordingly when transporting through changes in altitude.
• Meislin, H. W., Sanders, A. B., Meislin, H. W., & Daub, E. (1983). Alterations in MAST suit pressure with changes in ambient temperature.. The Journal of emergency medicine, 1(1), 37-44. doi:10.1016/0736-4679(83)90007-0
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  A study was undertaken to test the hypothesis that change in ambient air temperature has an effect on MAST suit pressure according to the ideal gas law. Two different MAST suits were tested on Resusci-Annie dummies. The MAST suits were applied in a cold room at 4.4 degrees C and warmed to 44 degrees C. Positive linear correlations were found in nine trials, but the two suits differed in their rate of increase in pressure. Three trials using humans were conducted showing increased pressure with temperature but at a lesser rate than with dummies. A correlation of 0.5 to 1.0 mm Hg increase in MAST suit pressure for each 1.0 degrees C increase in ambient temperature was found. Implications are discussed for the use of the MAST suit in environmental conditions where the temperature changes.
• Sanders, A. B. (1983). Association of cold weather with testicular torsion. Annals of Emergency Medicine, 12(6), 400. doi:10.1016/s0196-0644(83)80479-x
• Sanders, A. B. (1983). Diuresis or urinary alkalinization for salicylate poisoning: Prescott LF, Balali-Mood M, Critchley JA, et al Br Med J 285:1383–1386 Nov 1982. Annals of Emergency Medicine, 12(4), 276-277. doi:10.1016/s0196-0644(83)80634-9
• Sanders, A. B. (1983). Tinea capitis in Brooklyn. Annals of Emergency Medicine, 12(8), 525. doi:10.1016/s0196-0644(83)80676-3
• Sanders, A. B. (1983). Treatment of travellers diarrhea with trimethoprim/sulfamethoxazole and with trimethoprim alone: Dupont HL, Reeves RR, Galingo E, et al N Engl J Med 307:841–844 Sep 1982. Annals of Emergency Medicine, 12(2), 122. doi:10.1016/s0196-0644(83)80401-6
• Sanders, A. B., Kern, K. B., Ewy, G. A., Bailey, L., & Atlas, M. (1983). Improved survival from cardiac arrest with open chest massage. Annals of Emergency Medicine, 12(10), 138. doi:10.1016/s0196-0644(83)80232-7
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  with Open Chest Massage Arthur B Sanders, MD, Karl Kern, MD, Gordon A Ewy, MD, Matthew Atlas, Lynn Bailey Section of Emergency Medicine, Department of Surgery, and Section of Cardiology, Department of Internal Medicine, University of Arizona Health Sciences Center, Tucson There are no studies assessing the effect of open chest massage on survival from cardiac arrest. It has been shown that dogs cannot be resuscitated from prolonged ventr icular fibrillation (VF) and cardiopulmonary resuscitat ion (CPR) if their coronary perfusion pressure (CPP) cannot be ma in ta ined above 30 m m Hg. Accordingly, the canine model was used to determine if thoracotomy and open chest massage could improve survival when the CPP was less than 30 m m Hg after 15 minutes of VF and closed chest CPR. Ten mongrel dogs weighing 20.3 _+ 3.2 kg were anesthet ized wi th pentabarbi ta l (30 mm/kg) and intubated. The right femoral vein was cannulated and a 4 French bipolar pacing catheter was advanced into the right ventricle using ECG guidance. The r ight external jugular vein was cannulated, and a catheter was advanced into the right atrium. The right carotid artery was isolated, and a catheter was advanced into the thoracic aorta. Position of all catheters was confirmed during pos tmor tem examination. The aortic and right atrial catheters were attached to pressure transducers and a mul t i -channel polygraph to cont inuously record aortic and right atrial pressures. Subcutaneous ECG leads were at tached to the dogs' extremities. VT was electrically induced by passing a low-voltage (60-Hz) current through the pacing catheter. CPR was begun immediately Using the mechanical resuscitator set at a compression rate of 60/rain wi th a compression:vent i la t ion ratio of 5:1 and a 50% duty cycle. A compression force sufficient to compress the s ternum 2 inches was used. Ventilation was assisted through the endotracheal tube and the resuscitator using 100% oxygen and a vent i la t ion pressure of 18 cm. Closed chest CPR was continued for 15 minutes. During this time, the dogs were given epinephrine boluses in increasing doses from 0.5 mg to 3 mg every 2 minutes in at tempts to mainta in the CPP laortic minus right atrial diastolic pressure) above 30 m m Hg. At 15 minutes of VF, the coronary perfusion pressure was determined. If the CPP was greater than 30 m m Hg, the dog was excluded from the study; if the CPP was less than 30 m m Hg, the dog was entered into the study and alternatively assigned to the open chest massage (OCM) group or closed chest massage (CCM) group. At 15 minutes, dogs in the OCM group underwent thoracotomy and internal cardiac massage for 3 minutes. At 19 minutes of VF, the dogs were defibrillated wi th 10 joules. The dogs entered in the CCM group continued to receive ex te rna l CPR u n t i l 19 m i n u t e s of VF, w h e n they were defibrillated with 80 joules. At tempts at resuscitation continued for 5 minutes using subsequent doses of epinephrine, lidocaine, and atropine, and cardiac massage, as needed. The dogs were then observed for a total of 20 minutes post defibrillation. The animals were considered resuscitated if they demonstrated a normal sinus rhy thm and main ta ined an aortic pressure on their own at 20 minutes post resuscitation. After this determinat ion was made, the animals were sacrificed and a necropsy was performed. Four of the five dogs in the OCM group were resuscitated and survived for 20 minutes post defibrillation. None of the 5 dogs in the CCM group was resuscitated. This was a statistically significant difference by the Fisher's exact test (P < .05). Student t test analysis of the hemodynamic data showed significant differences between the OCM and CCM groups in the systolic and diastolic pressures and CPP at 1 and 2 minutes of open chest massage (P < .05). The results of this study indicate that survival can be improved using open chest massage when closed chest massage fails to produce an adequate coronary perfusion pressure. Prolongation of the QT Interval and Malignant Ventricular Dysrhythmia in Acute Myocardial Infarction Dale C Askins, DO, Wayne Seutter, DO Department of Emergency Medicine, Grand Rapids Osteopathic Hospital, Grand Rapids, Michigan A retrospective study of patients wi th acute myocardial infarct ion (AMI) was init iated to evaluate the relationship of a prolonged QT interval and malignant ventr icular dysrhythmia. Recent reports have elevated the significance of a long QT interval and l i fethreatening dysrhythmias. Frequent PVCs, multifocal PVCs, couplets, or R on T phenomenon in the face of AMI demands ant idysrhythmic prophylaxis. In those patients wi th AMI and no PVCs, a prolonged QT interval could define another subset at risk. Util izing the formula of Bazett,
• Zimmerman, M., Taft, T. V., Sanders, A. B., Ewy, G. A., & Alferness, C. A. (1982). Failure of one method of simultaneous chest compression, ventilation, and abdominal binding during CPR.. Critical care medicine, 10(8), 509-13. doi:10.1097/00003246-198208000-00005
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  Some modified methods of CPR improve carotid blood flow, but there are no studies to show that these modified techniques improve survival, Accordingly, an experimental CPR technique using simultaneous chest compression, ventilation (SCV-CPR), and abdominal binding was compared to standard CPR in beagle dogs. The modified technique utilized a broad-based bellows device that was mechanically compressed, producing chest compression, delivering a volume of air to the endotracheal tube, and pressurizing an abdominal binder. The duration of ventricular fibrillation and CPR was 5 min. Five of the 6 dogs could be resuscitated with standard CPR. None of 6 dogs could be resuscitated using this modified method of SCV-CPR and abdominal binding. The aortic diastolic pressure and the diastolic gradient between the aorta and right atrium was significantly different between the 2 groups. Because these pressures relate to the coronary perfusion pressure, they may explain the discrepancy in the survival rate. This study suggests increasing carotid blood flow during CPR will not necessarily improve survival.

Presentations

• Huber, K., Situ-LaCasse, E., & Sanders, A. B. (2019, October). Medical Ethics Curriculum Integration: Use of Mixed Teaching Methods in Third Year Medical Student Ethics Sessions. American Society for Bioethics and Humanities Annual Meeting. Pittsburgh, Pennsylvania.

Poster Presentations

• Sanders, A. B., Situ-LaCasse, E., & Huber, K. (2019, April). Medical Ethics Curriculum Integration: Use of Mixed Teaching Methods in Third Year Medical Student Ethics Sessions. University of Arizona College of Medicine Medical Education Research Day. Tucson, AZ.
• Amini, R., Breshears, E., Stolz, L. A., Stea, N., Hawbaker, N., Thompson, M., Sanders, A. B., & Adhikari, S. R. (2015, October). SNAPPY Teaching and Assessing Medical Students: Sonographic Assistance for Procedures in Preclinical Years. Research Forum of the American College of Emergency Physicians. Boston, MA: American College of Emergency Physicians.