Introduction: Opioid overdose (OD) is a growing cause of cardiac arrest in the US, spurred by the rise of illegally manufactured fentanyl and analogs. Naloxone is a reversal agent that can be administered by bystanders. Intra-nasal (IN) naloxone is now widely available in pharmacies across the US. Despite increasing access, minority populations remain disproportionately affected by drug overdose deaths. There are many free online opioid OD educational videos. Digital media can be a powerful tool for mass education, but the effectiveness is unknown. Research Question and Aims: The goal of this study was to evaluate online opioid overdose videos for content and gender/racial representation. Methods: We performed an online search with the query “how to give Narcan” (popular term for IN naloxone). Results were limited to the first 52 Google, 50 YouTube, and 60 TikTok videos. Exclusion criteria included: animal victim, duplicate, or no mention of naloxone. For each video, 2 reviewers evaluated content and identified the race and gender of featured characters. Disagreements were resolved through consensus. The race and gender of featured characters was compared using a two proportion z-test. Inter-rater reliability (IRR) for each data point was calculated using the arithmetic mean of Cohen's kappa. Results: Of 121 videos, the majority (87.6%) mentioned naloxone as a treatment for opioid OD; 62.8% provided instruction on how to administer IN naloxone, and 4.1% featured a testimonial. Only 43.0% provided a realistic visual demonstration of IN naloxone administration; 25.6% showed a realistic re-enactment of opioid overdose, and even fewer (19.0%) showed the dramatic response to naloxone. IRR was high for all categories. Videos predominantly featured white compared to non-white-appearing characters in both the victim (75.5 v. 17.8%, p< 0.00001) and rescuer roles (72.5 v 21.6%, p<0.00001). The rescuer gender was evenly distributed male v. female; however, the victim was more often male (77.8% v. 22.2%, p<0.00001). Conclusion: Most online opioid OD videos provide instructions on how to use IN naloxone, but do not feature realistic depictions of cardiac arrest caused by opioid OD, naloxone treatment, or response. There is a significant lack of racial diversity in these videos. Digital materials are needed with improved diversity and which teach learners how to RECOGNIZE and respond to opioid OD.

ABSTRACT In-hospital cardiac arrest resuscitation training often happens in silos, with minimal interprofessional training. The aim of this study was to implement and evaluate a simulation-enhanced, interprofessional cardiac arrest curriculum in a university hospital. The curriculum ran monthly for 12 months, training interprofessional teams of internal medicine residents, nurses, respiratory therapists, and pharmacy residents. Teams participated in a 90-min high-fidelity simulation including “code blue” (30 min) followed by a 30-min debriefing and a repeat identical simulated “code blue” scenario. Teams were tested in an unannounced mock Code Blue the following month. Advanced Cardiac Life Support (ACLS) algorithm adherence was assessed using a standardized checklist. In-hospital cardiac arrest (IHCA) incidence and survival was tracked for 2 years prior, during, and 1 year after curriculum implementation. Team ACLS-algorithm adherence at baseline varied from 47% to 90% (mean of 71 ± 11%) and improved immediately following training (mean 88 ± 4%, range 80–93%, p = .011). This improvement persisted but decreased in magnitude over 1 month (mean 81 ± 7%, p = .013). Medical resident self-reported comfort levels with resuscitation skills varied widely at baseline, but improved for all skills post-curriculum. This simulation-enhanced, spaced practice, interprofessional curriculum resulted in a sustained improvement in team ACLS algorithm adherence.

• Awareness of sudden cardiac arrest is low among competitive athletes. • There is little concern about sports-related cardiac arrest among competitive athletes, prior to recent high-profile events. • CPR is rarely (5% of identified cases) initiated by a fellow athlete in sports-related sudden cardiac arrest. • Strategic athlete-focused CPR and AED training could improve outcomes following SR-SCA events.

The MITRAL (Mitral Implantation of Transcatheter Valves) trial is the first prospective study for valve-in-mitral annular calcification (ViMAC), mitral valve-in-ring (MViR), and mitral valve-in-valve (MViV) using balloon-expandable aortic transcatheter heart valves. Procedural outcomes beyond 1 year are not well described.This study evaluated 2-year outcomes in ViMAC, MViR, and MViV in the MITRAL trial.This multicenter prospective study enrolled patients with severe MAC, prior failed mitral annuloplasty ring repair, or prior failed bioprosthetic MV replacement who were at high surgical risk at 13 U.S. sites.Between February 1, 2015, and December 31, 2017, 91 patients were enrolled (31 with ViMAC, 30 with MViR, and 30 with MViV). In the ViMAC group, 2-year all-cause mortality was 39.3%, 66.7% were New York Heart Association (NYHA) functional class I-II, and mean MV gradient was 5.6 ± 2.0 mm Hg. In the MViR group, 2-year all-cause mortality was 50%, 65% were NYHA functional class I-II, and mean MV gradient was 6.5 ± 2.7 mm Hg. In the MViV group, 2-year all-cause mortality was 6.7%, 85% were NYHA functional class I-II, and mean MV gradient was 6.9 ± 2.4 mm Hg. At 2 years, all patients had ≤mild mitral regurgitation and survivors in all 3 arms showed sustained improvement in Kansas City Cardiomyopathy Questionnaire scores compared to baseline.Use of balloon-expandable aortic transcatheter heart valves in selected patients with severe MAC, failed annuloplasty ring, and bioprosthetic MV dysfunction is associated with improvements in symptoms, quality of life, and stable prosthesis function at 2-year follow-up. Between 1 and 2 years, the MViR group experienced higher mortality rates than the MViV and ViMAC groups.

Out-of-hospital cardiac arrest (OHCA) remains a major public health problem. Even in high-income countries, survival rates have plateaued in the range of ten percent, stimulating an ongoing interest in developing novel approaches to resuscitation. Emergency Medical Services (EMS)-witnessed OHCAs constitute a subgroup of overall OHCA that occur after the arrival of EMS, leading to rapid initiation of resuscitation and significantly improved survival. In this narrative review we summarize and interpret recent developments in knowledge of EMS-witnessed OHCA regarding prevalence, demographics, location, circumstances, survival outcomes and clinical profile. We examine the possibility of informing novel resuscitation approaches and enhancing mechanistic knowledge by studying EMS-witnessed OHCA, with the goal of improving overall survival from OHCA.

Spindel, Jeffrey Fraser DO; Albers, Lauren MD; Brislin, Gregory MS; Toft, Lorrel Elizabeth Brown MD Author Information

While an agent-specific antidote for dabigatran, idarucizumab (Praxbind, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT), is approved for anticoagulation reversal,1 it is still not universally available, especially in rural hospitals. Therefore, anticoagulation reversal still represents an Achilles’ heel for novel oral anticoagulants (NOAC) in some clinical settings. Both vitamin K–dependent clotting factors such as prothrombin complex concentrate (PCC) and activated prothrombin complex concentrate (aPCC; FEIBA, Baxter Healthcare Corporation, Westlake Village, CA) have been studied in this role.

Introduction:Physical examination skills are receiving less attention in curricula and clinical practice, being supplanted by imaging and other technologies. We developed an online module to introduce auscultation of common cardiac murmurs to second-year medical students.Methods:The Murmur Online Learning Experience (MOLE) curriculum focused on nine common, unique, or highly testable cardiac murmurs, chosen collaboratively by the authors. The curriculum consisted of (1) a nine-item multiple-choice pretest containing a clinical vignette, a photo of stethoscope location, and an auditory clip; (2) nine modules each containing a several-minute-long auditory clip and a written description (location, quality, radiation, change with exam maneuvers); and (3) a nine-item multiple-choice posttest, identical to the pretest but randomly ordered. All second-year medical students at the University of Louisville were given access to MOLE during their cardiovascular curriculum and given an incentive to complete the ungraded activity.Results:One hundred forty-seven (91.8%) students voluntarily completed the pretest and posttest. The mean pretest score was 3.76 out of 9 (SD = 1.77). The mean posttest score was 7.14 out of 9 (SD = 1.78). Paired t-test results demonstrated a p value of <.001.Discussion:An online murmur curriculum consisting of repetitive auditory murmurs and narrative description of murmurs improved second-year medical students' ability to correctly identify common cardiac murmurs. This method of learning murmurs via online curriculum is a practical and effective way to hone students' physical exam skills in the modern era.

This study examines videos of cardiopulmonary resuscitation on Google and YouTube to discern the number that show women or female manikins and provide information to facilitate attempts to rescue women in cardiac arrest.

BACKGROUND:Out of hospital cardiac arrests, especially those due to ventricular tachyarrhythmias, have higher incidence in the morning. It is unknown whether in-hospital cardiac arrests follow a similar pattern. AIM OF THE STUDY:The purpose of this study was to analyze the circadian variation of in-hospital cardiac arrest incidence. METHODS:This retrospective review of data from the multicenter Get With The Guidelines-Resuscitation registry between 2000 and 2014 used multivariable hierarchical logistic regression analysis to examine circadian rhythm of in-hospital cardiac arrest over a 24-h cycle, stratified by initial shockable versus non-shockable rhythm. RESULTS:Among 154,038 patients, initial rhythm was recorded as asystole or pulseless electrical activity (non-shockable) in 124,918 (81%), and ventricular fibrillation or ventricular tachycardia (shockable) in 29,120 (19%). Among non-shockable events, the highest relative proportion occurred during 0400-0759 (17.9%), followed by 0000-0359 (17.1%). For shockable rhythms the greatest relative proportion occurred between 2000-2359 (17.0%), followed by 1200-1559 (16.9%). Multivariable analysis showed that the relative risk of non-shockable compared to shockable arrest was slightly higher from midnight through 0359 (aOR 1.13; 95% CI 1.06-1.20, p < 0.001) and from 0400 through 0759 h (aOR 1.14; 95% CI 1.07-1.22, p < 0.001). Although statistically significant, the magnitude of difference in incidence by time of day was small in both groups. CONCLUSIONS:Although small differences in the relative frequency of in-hospital cardiac arrest (both shockable and non-shockable rhythms) were noted during different time intervals, in-hospital cardiac arrest occurs with nearly equal frequency throughout the day. Our findings have important implications for hospital staffing models to ensure that quality of resuscitation care is consistent regardless of time.

Introduction: Bystander cardiopulmonary (CPR) improves survival following out-of-hospital cardiac arrest (OHCA). However, women are less likely than men to receive CPR in public locations. Female-specific issues such as fear of touching breasts have been identified as barriers to performing CPR on women. The purpose of this study was to quantify and evaluate online CPR instructional films featuring a female victim. Methods: Using the search query “how to do CPR” via Google and YouTube, 374 and 500 films (38 and 25 result pages), respectively, were reviewed in May 2019. Exclusion criteria included: non-English, non-instructional, pediatric or animal victim, duplicates, parity, or in-hospital cardiac arrest. We identified 11 films featuring a female victim. These films were scored on 6 key aspects of CPR education: scene safety, check responsiveness, activate Emergency Medical Services, proper hand position, accurate rate, and appropriate depth of compressions. Results: Of the 874 reviewed films, 11 featured a female victim. Just 5 films were high-quality (correctly addressing 5 or 6 key aspects of CPR training, Figure 1). Furthermore, 2 of the 5 high-quality instructional films taught rescue breathing, which is no longer a recommended component of bystander CPR in the U.S. The remaining 3 films were all created outside the U.S. (Australia, New Zealand, England). None of the films explicitly addressed barriers to performing CPR on a female, including fear of touching breasts or concerns about causing harm. Conclusion: Out of the billions of films available online, we identified only 3 high-quality instructional films teaching modern, hands-only CPR featuring a female victim, none of which addressed specific female-related CPR issues. This gender disparity can be addressed with high-quality CPR training films that feature a female victim and explicitly address previously-identified barriers to performing CPR on a female.

Optimal approach to right ventricle (RV) thrombus remains unknown. A 71 year old male recently diagnosed with stage 4 lung adenocarcinoma presented with shortness of breath. Three weeks ago, he was treated for pulmonary embolism with therapeutic enoxaparin. His heart rate was 120/minute, blood

Every year over 350 000 Americans experience an out-of-hospital cardiac arrest; most will not survive. Provision of bystander cardiopulmonary resuscitation improves mortality after cardiac arrest. Yet, our current methods for public cardiopulmonary resuscitation training are burdensome and ineffective. Now is the time for funding agencies to prioritize the rigorous scientific study of established and novel cardiopulmonary resuscitation training methods to create a more efficient and effective program. In so doing, we can arm the public with this vital skill and empower them to save lives.

Cardiopulmonary resuscitation (CPR) training in high schools is required by law in the majority of U.S. states. However, laws differ from state to state, and it is unknown how this legislation is being enacted. The authors sent a cross-sectional, closed survey to educational superintendents in 32 states with CPR laws in June 2016. The authors subsequently performed direct examination and categorization of CPR legislation in 39 states (several states passed legislation as of September 2017). Survey results indicated differing practices with regard to CPR instruction in areas such as course content (63% perform automated external defibrillator training), instructor (47% used CPR-certified teachers/coaches, 30% used other CPR-certified instructors, 11% used noncertified teachers/coaches), and method (7% followed American Red Cross methods, 55% followed American Heart Association methods). CPR laws differ, although almost all (97%) require hands-on training. Although hands-on practice during CPR instruction in high school is required by law in the majority of U.S. states, there is currently no standardized method of implementation.