CPR STUDY SOURCED FROM REUTERS HEALTH

Cardiopulmonary resuscitation (CPR), whether performed in-hospital or during  out-of-hospital cardiac arrest, often fails to meet guideline recommendations,  according to two reports in the Journal of the American Medical Association for  January 19.

Dr. Lars Wik, at Ulleval University Hospital in Oslo, Norway, and colleagues  used a sternal pad fitted with an accelerometer and a pressure sensor to measure  the quality of out-of-hospital CPR performed by ambulance personnel. The  paramedics and nurse anesthetists involved had undergone a refresher course in  advanced cardiac life support immediately prior to the study period.

Included in their case series were 176 adult patients treated in Stockholm,  London, and Akershus, Norway, between March 2002 and October 2003.

The results show that chest compressions were being given only half of the  available time during resuscitation events; only about 20% of this time without  CPR was taken up by electrocardiographic analysis and defibrillation.

The mean compression rate was 121/minute when being delivered, averaging out  to 64/minute, whereas advanced cardiac life support (ACLS) guidelines recommend  100/minute. Mean compression depth was 34 mm, and only 28% of compressions had  the recommended depth of 38 mm to 51 mm.

Altogether, 61 patients (35%) achieved spontaneous circulation, 34 (19%) were  admitted to the hospital and six (3%) were discharged alive.

"There is a great opportunity to improve CPR quality and, hopefully, patient  survival by focusing on delivery of chest compressions of correct depth and  rate, with minimal 'hands-off' periods," Dr. Wik and his team conclude.

Dr. Lance B. Becker and colleagues performed a similar analysis of 67  patients who experienced in-hospital cardiac arrest at the University of Chicago  Hospitals.

During the first 5 minutes of resuscitation, chest compression rate was less  than 90/minute 28.1% of the time and less than 80/minute 12.8% of the time.  Chest compressions were less than 38 mm 37.4% of the time. Ventilation rates  tended to be high, exceeding 20/minute 60.9% of the time, compared with  recommended rates of 12 to 16/minute.

There was return of spontaneous circulation in 27 patients (40.3%), but only  seven (10.4%) survived to hospital discharge.

Dr. Becker's group proposes that mechanical devices that can provide chest  compressions reliably at a set rate and depth may offer better hemodynamic  characteristics than manual chest compressions. Another possible option is the  use of monitors that can provide audio feedback during CPR.

Training courses in ACLS become more complex each time they are revised, Drs.  Arthur B. Sanders and Gordon A. Ewy note in a related editorial.

"It is time to be more realistic and change the model used for training... in  CPR," they write. "The initial step is to accept the fact that human beings will  be performing CPR and ACLS and to focus on simplifying the technique."

Otherwise, write the two physicians, based at the University of Arizona  College of Medicine in Tucson, "the unintended consequences of the complex basic  life support/ACLS algorithms are too many interruptions in chest compressions,  too many rescue breaths, not enough compressions, and not enough survivors."

JAMA 2005;293:299-310,363-365.

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Medication calculation skills of practicing paramedics.
              
Hubble MW, Paschal KR, Sanders TA
Department of Health Sciences, Western Carolina University, Cullowhee, North Carolina 28723, USA.  
Contact: mhubble@wpoff.wcu.edu

OBJECTIVE: To assess the medication calculation skills among a group of practicing paramedics, the types of computations they find most difficult, and the relationship between drug calculation skills and various demographic characteristics.

METHODS: A demographic survey and a ten-item drug calculation examination were administered to a convenience sample of 109 practicing paramedics representing a cross-section of emergency medical services (EMS) system characteristics in North Carolina. Examinations were scored independently by two graders and error types were assigned to incorrect responses. Examination results were then correlated with demographic and EMS system characteristics.

RESULTS: Overall performance on the drug calculation examination was poor.   The mean score was 51.4% (SD 27.4). Intravenous flow rate problems and medication bolus problems were calculated correctly in 68.8% of the cases, followed by non-weight-based medication infusions (33.9%), weight-based medication infusions (32.5%), and percentage-based medication infusions (4.5%)               Examination scores were higher among paramedics with college level education, but scores were lower among paramedics with more years of EMS experience.

Conceptual errors (i.e., errors in setting up the problem) were more prevalent than mathematical errors, errors in weight conversion, or errors in unit conversion (e.g., grams to milligrams). The participants reported that drug calculations were infrequently performed in daily practice and were rarely a topic of continuing education programs.

CONCLUSION: Similar to findings among other allied health professions, medication calculation skills were found to be lacking among a group of practicing paramedics. In addition, the paramedics reported infrequent opportunities to perform this skill in the clinical setting and that medication calculations were not a routine part of EMS continuing education programs.