Both studies were completed in an average of six seconds, which allowed for rapid confirmation with minimal risk of desaturation. Additionally, this examination could be performed while capnography was being obtained, with both confirmatory methods used to support each other in equivocal cases. Operator confidence was high with both techniques, suggesting that both providers felt comfortable with their assessments, which is an important finding in ultrasound studies because, if the operator is not confident in their assessment, they will be unlikely to use the examination clinically.It is important to consider several limitations with respect to this study. First, it was performed in a cadaver model, which may not fully reflect the characteristics of a live patient. However, cadaver models have been used extensively for the evaluation of ultrasound for ETT confirmation and have demonstrated similar test characteristics to live patients for this modality.Additionally, we used only three cadavers in the study and it is possible this may not have fully represented the wider population. However, we intentionally used cadavers with significant differences in anatomy to best represent the variation in a larger population. It is possible that the repeat intubations may have improved the accuracy of the sonographers due to increased practice. To avoid this we alternated cadavers and techniques between each use to reduce the potential for improving each sonographer’s learning curve during the study. While it is not possible to completely exclude the potential for sonographers to have improved their accuracy throughout the study, this was not supported by the data as equivalent numbers of misidentified ETT placements occurred in the early and later intubations. There is also no reason to suggest that this would differentially affect one technique over another.
Moreover, this study was designed to evaluate the test characteristics of dynamic vs. static sonography for ETT localization. Therefore, it is important to ensure similar rates of tracheal and esophageal intubation,hydroponics system for cannabis which would not be possible in an ED setting due to low overall rates of esophageal intubation.Because this study was performed by two sonographers with prior experience using ultrasound for ETT confirmation, it is possible that the results may have differed if less experienced sonographers were used. However, the use of ultrasound for ETT confirmation has been suggested to have a rapid learning curve.Nonetheless, further studies are advised to determine whether the accuracy of static vs. dynamic techniques differs in less experienced providers.Atrial fibrillation , a supraventricular tachyarrhythmia, is the primary diagnosis for over 467,000 hospitalizations each year.The AFFIRM trial compared rate and rhythm control in 4,060 chronic AF patients. It found no difference in overall mortality, but there were fewer hospitalizations with rate control compared to rhythm.The subsequent RACE II trial established that lenient heart rate control was as effective as strict control in preventing cardiovascular events and required fewer outpatient visits to achieve the goal HR.A number of medications are used for rate control including beta blockers and non-dihydropyridine calcium channel blockers.Diltiazem, a non-dihydropyridine calcium channel blocker, is a common initial choice in the management of AF with rapid ventricular response due to its ability to be given as an intravenous push, continuous infusion, and oral immediate-release or extended-release tablet. In the ED a loading dose of IV diltiazem is usually administered followed by PO immediate-release tablet or IV continuous infusion. Both options allow for dose titration in the short term before converting to a longer-acting PO formulation for discharge.
The PO immediate-release diltiazem tablet has an onset of action of 30-60 minutes and is dosed every six hours.IV continuous infusion diltiazem has a rapid onset of action and is titrated every 15-30 minutes. The route of diltiazem after the initial IV LD can influence the disposition of the patient from the ED, the level of care needed, and hospital length of stay. Patients who receive only the PO immediate-release diltiazem absorb a therapeutic dose quickly and can generally be discharged or admitted to a general medicine floor, but cannot be titrated more frequently than every six hours. Patients who received the IV continuous infusion must have their dose frequently titrated by nursing and often require stepdown care. No studies exist comparing the efficacy of PO immediate-release and IV continuous-infusion diltiazem in the emergent management of AF with RVR. The objective of this study was to compare the incidence of treatment failure at four hours between PO immediate-release and IV continuous-infusion diltiazem after an IV LD.We collected and managed study data using REDCap® electronic data capture tools.Baseline demographic information recorded included the patient’s age, sex, race, and weight. Diltiazem dosing characteristics at baseline and four hours and the use of adjunctive medication for HR or rhythm control at four hours were collected. Clinical outcomes recorded included HR and blood pressure at baseline and four hours, ED disposition,indoor hydroponics cannabis and hospital LOS. Two of the study’s investigators abstracted all available data independently. Both were involved in the study design and used a standardized data collection form in REDCap® that included study definitions to ensure consistency between the investigators. Investigators were not blinded to the study outcome. Any discrepancies between abstractors resulted in a collaborative review of the chart by both investigators until discrepancies were resolved. As a result, interrater reliability was not determined.
The primary endpoint of the study was the percentage of patients with treatment failure at 4 ± 1 hour after initiation of PO immediate-release diltiazem or continuous IV diltiazem infusion. Treatment failure was defined as HR of > 110 beats/min at 4 ± 1 hour, a switch in therapy from PO immediate-release diltiazem to IV continuous infusion diltiazem, the requirement of an additional IV diltiazem bolus within four hours from the start of PO or IV continuous infusion, or addition/switch of therapy to another rate control or antiarrhythmic agent within four hours. A clinical endpoint of 4 ± 1 hour was selected to give time for both the PO and the IV diltiazem to have therapeutic effect. It was also concluded that this was a reasonable amount of time for the ED provider to determine disposition. We made the decision not to include time points extending beyond four hours due to the increased number of confounding factors, including the conversion to PO β-blockers or extended-release PO diltiazem. Patient characteristics collected included age, weight, race, sex, initial HR and BP, and initial diltiazem LD. We assessed the safety endpoint of clinically significant hypotension by recording the indication for diltiazem discontinuation and the need for vasopressors administration for hemodynamic support.In the emergent setting, diltiazem has been shown to be superior to digoxin, metoprolol, and amiodarone in the initial management of AF and flutter.IV diltiazem has often been considered superior to PO in the management of AF due its 100% bioavailability and titratability. However, PO immediate-release diltiazem confers many benefits over IV continuous infusion including a fast onset of action, minimal titration requirement, decreased nursing resources, and the ability to disposition to a general floor or possibly discharge home. A comparison of PO immediate-release and IV continuous-infusion diltiazem in the emergent clinical setting had never been performed. In our study, we found that PO immediate-release diltiazem resulted in a 0.4 OR of treatment failure when compared to IV continuous infusion. In other words, PO immediate-release diltiazem resulted in an odds of heart rate control 2.6 times greater than IV continuous infusion at four hours.
This is a surprising result given the higher bio-availability of the IV route compared to the oral formulation. A possible reason for this difference in treatment failure may be that IV continuous infusion was sub-optimally titrated. In our sample, the median hourly dose of the IV continuous infusion at four hours was only 10 mg/h, well below the maximum dose of 15 mg/h. Slow titration to sub-maximal doses may have resulted in sub-optimal diltiazem plasma concentrations in comparison with patients who were given immediate-release PO diltiazem. In theory, PO dosing may have achieved a higher plasma concentration as a result of the entire diltiazem dose being given at once. Therefore, our results may not reflect the comparison of two treatment regimens at optimal dosing capacity, but rather the real-world practice in which medication titration is not always optimized. PO diltiazem was associated with statistically significant higher odds of being admitted to the general floor and lower odds of being admitted to stepdown or the ICU. Patients who received PO also had a two-day shorter median LOS compared to IV. While the differences in these two parameters cannot be ascertained in a definitive manner due to the retrospective nature of the study, it is possible that the extended time needed to transition patients from IV to PO diltiazem before discharge may have played a contributing factor. Patient disposition and decreased LOS represent a possible area of healthcare cost savings that should be investigated in future prospective studies. Providers may choose IV continuous-infusion diltiazem if they want to titrate to lower doses in patients with borderline hemodynamic stability. In our study, however, clinically significant hypotension did not occur in the PO or IV group. Overall, our findings call in to question the primacy of IV continuous-infusion diltiazem for AF. PO diltiazem was associated with a lower rate of treatment failure and higher rate of heart control than IV continuous infusion and with similar safety. Importantly, these findings are the result of a retrospective study with limited sample size and therefore must be confirmed in a larger, prospective, randomized controlled trial.Each year 395,000 people suffer an out-of-hospital cardiac arrest in the United States.Multiple studies have demonstrated that layperson CPR increases chance of survival by 2-3 fold.The importance of immediate response by the public has been highlighted by the Institute of Medicine report “Strategies to Improve Cardiac Arrest Survival: A Time to Act”.One of the key recommendations of the IOM report was a call to “foster a culture of action through public awareness and training” to reduce the risk of irreversible neurologic injury and functional disability.Wide disparities in bystander CPR rates and OHCA outcomes persist, with some communities reporting a five-fold difference in survival.Residents who live in neighborhoods that are primarily Black, Hispanic, or low income are more likely to have an OHCA, less likely to receive bystander CPR, and are less likely to survive.The implementation of creative new strategies to increase layperson CPR and defibrillation may improve resuscitation in priority populations.Most communities will only improve survival through a multifaceted, community-wide approach that may include teaching hands-only CPR for bystanders,emphasis on brief educational videos16 and video self-instruction,mandatory school-based training,and dispatcher-assisted CPR.One particularly high-yield approach for high-risk communities is the implementation of mandatory CPR training in high schools.The American Heart Association , the World Health Organization, and the IOM along with multiple other national and international advocacy groups have endorsed CPR training in high school as a key foundation to improve OHCA survival outcomes.The 2015 IOM report calls for state and local education departments to partner with training organizations and public advocacy groups to promote and facilitate CPR and automated external defibrillator training as a high school graduation requirement.Today communities across the U.S. have recognized the value of CPR training in high schools, and 36 states have enacted laws calling for mandatory training prior to graduation.The benefit of CPR training in high schools is understood as a long-term investment to ensure that multiple generations are trained and ready to act.However, a more immediate consequence of school centered training may be the amplification of community CPR training and literacy as students become trainers for their household and circle of friends.Students can be asked to “pay it forward” by sending them home with CPR training materials and assigning them the task of training friends and family members. This pilot program sought to investigate the feasibility, knowledge acquisition, and dissemination of a high school centered, CPR video self-instruction program with a “pay-it-forward” component in a low-income, urban, predominantly Black neighborhood with historically low bystander-CPR rates. Schools provide large-scale, centrally organized community settings accessible to both children and adult family members of all socioeconomic backgrounds. A student-mediated, CPR educational intervention may be an effective conduit to relay OHCA knowledge and preparedness in high-risk neighborhoods.