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Background: In Europe, approximately 291,000 cardiac arrests occur annually. Despite critical care therapy, hospital mortality remains high. This systematic review assessed whether, in comatose survivors of cardiac arrest, any drug therapy, compared to placebo or usual care, improves outcomes., Methods: We searched Medline, EMBASE, the Cochrane Central Register of Controlled Trials, and The International Clinical Trials Registry Platform for randomized controlled trials of drug therapy in comatose survivors of cardiac arrest (last searched 20th October 2024). The primary outcome was mortality at 30 days/hospital discharge. Other outcomes reflected those of the Core Outcome Set for Cardiac Arrest. Risk of bias was assessed using Cochrane Risk-Of-Bias Version 1. Studies of steroids, coenzyme Q10 and thiamine were meta-analysed., Results: From 2562 records, 207 full texts were screened and 45 studies (5800 patients) investigating 30 therapies were included. Studies were grouped thematically as supportive drug therapies (n = 10), neuroprotective agents (n = 19), and anti-inflammatory/antioxidants (n = 16). Four studies reported reduced mortality at 30 days/hospital discharge: one of the anticholinergic penehyclidine hydrochloride, two of intra-arrest vasopressin and methylprednisolone plus hydrocortisone for post resuscitation shock, and one of the traditional Chinese medicine, shenfu. Studies of steroids, coenzyme Q10 and thiamine were meta-analysed. We could not detect an effect on mortality with steroids (n = 739, risk ratio (RR), 0.93; 95 % CI 0.83-1.04, p = 0.21; I 2  = 60 %, low certainty), coenzyme Q10 (n = 107, RR, 0.91; 95 % CI 0.61-1.37, p = 0.65; I 2  = 0 %, low certainty), or thiamine (n = 149, RR, 1.11; 95 % CI 0.88-1.40, p = 0.39; I 2  = 0 %, very low certainty)., Conclusion: In comatose survivors of cardiac arrest, the majority of trials of drug therapy reported no effect on mortality. Meta-analyses of steroids, coenzyme Q10 and thiamine demonstrated no evidence of an effect on mortality. However, the low certainty of evidence warrants further research., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: LMCH reports receiving support from the Health Research Board Ireland, Clinical Trial Network Award CTN 2021-010. LMCH’s work also includes the investigator initiated TAME and STEPCARE trials in Ireland. ADN reports receiving support from the Health Research Board Ireland, Clinical Trial Network Award CTN 2021-010. ADN was the Principal Investigator for the completed and published investigator-initiated TAME trial and National Investigator for the STEPCARE trial. MBS reports receiving lecture fees from Bard Medical (Ireland) in 2021 and 2022. DFMA reports receiving grants from NIHR, Innovate UK, MRC, Novavax, Northern Ireland HSC R&D division, Randox, Wellcome Trust. DFM, through Queen’s University Belfast, holds a patent for novel treatment for inflammatory disease (USB962032). DFM reports receiving consulting fees from Bayer, Aptarion, Direct Biologics, Aviceda, GlaxoSmithKline, Boehringer Ingelhelm, Novartis, Eli Lilly and SOBI. DFM reports receiving honoraria from GlaxoSmithKline. DFM reports participation on a Data Safety Monitoring Board for Vir Biotechnology, Inc and Faron Pharmaceuticals. DFM holds leadership roles with Intensive Care Society, MRC/NIHR and NIHR. DFM’s spouse has received consultancy fees from Insmed and payment for participation in a grant review panel for California Inst For Regenerative Medicine. The remaining authors declare that they have no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

We present the case of a 17-year-old female who survived cardiac arrest caused by a massive pulmonary embolism leading to obstructive shock. Despite a prolonged low-flow period of 193 minutes, she fully recovered without apparent neurological damage, thanks to immediate cardiopulmonary resuscitation (CPR) initiated by her father, timely intervention by paramedics and medical teams, and the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Key factors in her recovery included the absence of a no-flow period, maintenance of end-tidal CO 2 (ETCO 2 ) levels above 25-30 mmHg during resuscitation, and the vital role of VA-ECMO in supporting organ perfusion. This case highlights the importance of prompt bystander intervention, continuous ETCO 2 monitoring during CPR, and the integration of advanced circulatory support measures in post-cardiac arrest care. Additionally, it underscores the potential for favorable neurological outcomes even after extended resuscitation, provided there is adequate cerebral perfusion and timely mechanical support. The report emphasizes the need for public education on basic life support (BLS)., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Paciorkowski et al.)

Introduction and Objective: Sudden cardiac arrest (SCA) is a significant cause of adult mortality, categorized into in-hospital (IHCA) and out-of-hospital (OHCA). Survival in OHCA depends on early diagnosis, alerting Emergency Medical Service (EMS), high-quality bystander resuscitation, and prompt Automatic External Defibrillator (AED) use. Accelerating technological progress supports faster AED retrieval and use, but there are barriers in real-life OHCA situations. The study assesses 6th-year medical students' ability to locate AEDs using smartphones, revealing challenges and proposing solutions., Material & Methods: The study was conducted in 2022-2023 at the Medical University of Lodz, Poland. Respondents completed a survey on AED knowledge and characteristics, followed by a task to find the nearest AED using their own smartphones. As common sources did not list the University AEDs, respondents were instructed to locate the nearest AED outside the research site., Results: A total of 300 6th-year medical students took part in the study. Only 3.3% had an AED locating app. Only 32% of students claimed to know where the AED nearest to their home is. All 300 had received AED training, and almost half had been witness to a resuscitation. Out of the 291 medical students who completed the AED location task, the median time to locate the nearest AED was 58 s. Most participants (86.6%) found the AED within 100 s, and over half (53%) did so in under 1 min., Conclusions: National registration of AEDs should be mandatory. A unified source of all AEDs mapped should be created or added to existing ones. With a median of under one minute, searching for AED by a bystander should be considered as a point in the chain of survival., (© 2024. The Author(s).)

Background: The "chain of survival" was first systematically addressed in 1991, and its sequence still forms the cornerstone of current resuscitation guidelines. The term "chain of survival" is widely used around the world in literature, education, and awareness campaigns, but growing heterogeneity in the components of the chain has led to confusion. It is unclear which of these emerging chains is most suitable, or if adaptations are needed in particular contexts to depict key actions of resuscitation in the 21st century. This scoping review provides an overview of the variety of chains of survival described., Objectives: To identify published facets of the chain of survival, to assess views and strategies about adapting the chain, and to identify reports on how the chain of survival affects teaching, implementation, or patient outcomes., Methods Eligibility Criteria and Sources of Evidence: A scoping review as part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR) was conducted. MEDLINE(R) ALL (Ovid), Embase (Ovid), APA PsycINFO (Ovid), CINAHL (Ebscohost), ERIC (Ebscohost), Web of Science (Clarivate), Scopus (Elsevier), and Cochrane Library (Wiley Online) were searched. All publications in all languages describing chains of survival were eligible, without time restrictions. Due to the heterogeneity and publication types of the relevant studies, we did not pursue a systematic review or meta-analysis., Results: A primary search yielded 1713 studies and after screening we included 43 publications. Modified versions of the chain of survival for specific contexts were found (e.g., in-hospital cardiac arrest or paediatric resuscitation). There were also numerous versions with minor adaptations of the existing chain. Three publications suggested an impact of the use of the chain of survival on patient outcomes. No educational or implementation outcomes were reported., Conclusion: There is a vast heterogeneity of chain of survival concepts published. Future research is warranted, especially into the concept's importance concerning educational, implementation, and clinical outcomes., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Background: In the chain of survival for Out-of-hospital cardiac arrest (OHCA), each component of care contributes to improve the prognosis of the patient with OHCA. The SARS-CoV-2 (COVID-19) pandemic potentially affected each part of care in the chain of survival. The aim of this study was to compare prehospital care, in-hospital treatment, and outcomes among OHCA patients before and after the COVID-19 pandemic., Methods: We analyzed data from a multicenter prospective study in Kanto area, Japan, named SOS-KANTO 2017. We enrolled patients who registered during the pre-pandemic period (September 2019 to December 2019) and the post-pandemic period (June 2020 to March 2021). The main outcome measures were 30-day mortality and the proportion of favorable outcomes at 1 month, and secondary outcome measures were changes in prehospital and in-hospital treatments between the pre- and post-pandemic periods., Results: There were 2015 patients in the pre-pandemic group, and 5023 in the post-pandemic group. The proportion of advanced airway management by emergency medical service (EMS) increased (p < 0.01), and EMS call-to-hospital time was prolonged (p < 0.01) in the post- versus pre-pandemic group. There were no differences between the groups in defibrillation, extracorporeal membrane oxygenation, or temperature control therapy (p = 0.43, p = 0.14, and p = 0.16, respectively). Survival rate at 1 month and favorable outcome rate at 1 month were lower (p = 0.01 and p < 0.01, respectively) in the post- versus pre-pandemic group., Conclusion: Survival rate and favorable outcome rate 1 month after return of spontaneous circulation of OHCA worsened, EMS response time was prolonged, and advanced airway management by EMS increased in the post- versus pre-pandemic group; however, most prehospital and in-hospital management did not change between pre- and post-COVID-19 pandemic., (© 2024. The Author(s).)

Sudden cardiac arrest is a global problem and is considered the third leading cause of death in industrialized countries. Patient survival rates after out-of-hospital cardiac arrest (OHCA) vary significantly between countries and continents. In particular, the 2021 European Resuscitation Council (ERC) Resuscitation Guidelines place a special focus on the chain of survival of patients after OHCA. As a complex, interconnected approach, the focus is on: Raising awareness for cardiac arrest and lay resuscitation, school children's education in resuscitation "KIDS SAVE LIVES", first responder systems - technologies to engage the community, telephone-assisted resuscitation (telephone-CPR; T-CPR) by dispatchers, and cardiac arrest centers (CAC) for further treatment in specialized hospitals. The Systems Saving Lives approach is a comprehensive strategy that emphasizes the interconnectedness of all links in the chain of survival following an OHCA, with a particular focus on the relationship between the community and emergency medical services (EMS). This system-level approach emphasizes the importance of the connection between all those involved in the chain of survival. It has a high potential to improve overall survival after OHCA. Therefore, it is recommended that these strategies be promoted and expanded in all countries., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Lina Horriar and Nadine Rott are employees of the German Resuscitation Council. Nadine Rott is member of editorial board of Resuscitation plus and member of ILCOR Communications Committee. Bernd W. Böttiger is treasurer of the European Resuscitation Council (ERC), Founder of the ERC Research NET, Chairman of the German Resuscitation Council (GRC), Member of the „Advanced Life Support (ALS) Task Force of the International Liaison Committee on Resuscitation (ILCOR), Member of the Executive Committee of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), Founder of the “Deutsche Stiftung Wiederbelebung”, Federal Medical Advisor of the German Red Cross (DRK), Member of the Advisory Board of the “Deutsche Herzstiftung”, Co-Editor of “Resuscitation”, Editor of the Journal “Notfall + Rettungsmedizin”, Co-Editor of the Brazilian Journal of Anesthesiology. He received fees for lectures from the following companies: Forum für medizinische Fortbildung (FomF), Baxalta Deutschland GmbH, ZOLL Medical Deutschland GmbH, C.R. Bard GmbH, GS Elektromedizinische Geräte G. Stemple GmbH, Novartis Pharma GmbH, Philips GmbH Market DACH, Bioscience Valuation BSV GmbH., (© 2023 The Author(s).)

Aim: Out-of-hospital cardiac arrest (OHCA) contributes to substantial mortality, but its resuscitation status in China is unknown. We aimed to describe and analyze out-of-hospital cardiac arrest in terms of Chain of Survival., Methods: We systematically collected Utstein-style publications. Scenarios were prespecified, including either emergency medical service (EMS) assessing and attending cardiac arrest, resuscitation attempted by a bystander, resuscitation attempted by EMS, or in-hospital treatment. Random-effect models were used in a meta-analysis to pool rate ratios (RRs) with 95% confidence intervals (CIs) from multiple cohorts., Results: We analyzed 59 Chains involving 233,376 Chinese patients. The median rate of survival to discharge (interquartile range) was 0.35 % (0.06 %-0.61 %), 3.66 % (3.06 %-3.85 %), 1.23 % (0.57%-1.36%), and 2.73% (2.04%-3.42%) for four scenarios. The rate was significantly higher for bystander resuscitation than for EMS (P = 0.025) or in-hospital treatment (P = 0.301). However, only 4.8 % (1.6 %-8.2 %) of patients received bystander resuscitation, with no bystander defibrillation and a median response time of 9-15 minutes for EMS. Compared with controls without witnesses, arrest being witnessed and with bystander resuscitation increased rates of survival to discharge by 1.97 (I 2  = 0, P for I 2  = 0.583; pooled RR 2.97; 95% CI 1.47-6.02) and 6.79 (I 2  = 0, P for I 2  = 0.593; pooled RR 7.79; 95 % CI 3.40-17.84) times, following a markedly increasing trend., Conclusions: A low probability of first aid at multiple points is linked to poor survival following OHCA. It is essential to strengthen front links in the Chain of Survival in China, including among witnesses, bystanders, and emergency response., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Objective: Over 300 000 cases of out-of-hospital cardiac arrests (OHCAs) occur each year in the USA and Europe. Despite decades of investment and research, survival remains disappointingly low. We report the trends in survival after a ventricular fibrillation/pulseless ventricular tachycardia OHCA, over a 13-year period, in a French urban region, and describe the simultaneous evolution of the rescue system., Methods: We investigated four 18-month periods between 2005 and 2018. The first period was considered baseline and included patients from the randomised controlled trial 'DEFI 2005'. The three following periods were based on the Paris Sudden Death Expertise Center Registry (France). Inclusion criteria were non-traumatic cardiac arrests treated with at least one external electric shock with an automated external defibrillator from the basic life support team and resuscitated by a physician-staffed ALS team. Primary outcome was survival at hospital discharge with a good neurological outcome., Results: Of 21 781 patients under consideration, 3476 (16%) met the inclusion criteria. Over all study periods, survival at hospital discharge increased from 12% in 2005 to 25% in 2018 (p<0.001), and return of spontaneous circulation at hospital admission increased from 43% to 58% (p=0.004).Lay-rescuer cardiopulmonary resuscitation (CPR) and telephone CPR (T-CPR) rates increased significantly, but public defibrillator use remained limited., Conclusion: In a two-tiered rescue system, survival from OHCA at hospital discharge doubled over a 13-year study period. Concomitantly, the system implemented an OHCA patient registry and increased T-CPR frequency, despite a consistently low rate of public defibrillator use., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Whether and how bystander cardiopulmonary resuscitation (CPR) modifies the cardiac rhythm after out-of-hospital cardiac arrest (OHCA) over time remains unclear. We investigated the association between bystander CPR and the likelihood of ventricular fibrillation (VF) or ventricular tachycardia (VT) as the first documented cardiac rhythm., Methods: We identified individuals with witnessed OHCA of cardiac origin from a nationwide population-based OHCA registry in Japan between 1 January 2005 and 31 December 2019. The first documented cardiac rhythm was compared between patients who received bystander CPR and those who did not, using a 1:2 propensity score-matched analysis., Results: Of 309 900 patients with witnessed OHCA of cardiac origin, 71 887 (23.2%) received bystander CPR. Propensity score matching paired 71 882 patients who received bystander CPR with 143 764 who did not. The likelihood of detecting a VF/VT rhythm was significantly higher among patients who received bystander CPR than among those who did not (OR 1.66; 95% CI 1.63 to 1.69; p<0.001). Comparing the two groups at each time point, the difference in the proportions of patients with VF/VT rhythms peaked at 15-20 min but was insignificant at 30 min postcollapse (15 min after collapse; 20.9% vs 13.9%; p<0.001). The likelihood of a pulseless electrical activity rhythm was significantly lower in patients who received bystander CPR during the first 25 min postcollapse (15 min after collapse; 26.2% vs 31.5%; p<0.001). The two groups had no significant difference in the likelihood of asystole (15 min after collapse; 51.0% vs 53.3%; p=0.078)., Conclusion: Bystander CPR was associated with a higher VF/VT likelihood and a lower likelihood of pulseless electrical activity at first documented rhythm analysis. Our results support early CPR for OHCA and highlight the need for further research to understand whether and how CPR modifies the cardiac rhythm after arrest., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: To determine whether out-of-hospital cardiac arrest (OHCA) post-resuscitation management and outcomes differ between four Detroit hospitals., Introduction: Significant variation exists in treatment/outcomes from OHCA. Disparities between hospitals serving a similar population is not well known., Methods: Retrospective OHCA data was collected from the Detroit-Cardiac Arrest Registry (DCAR) between January 2014 to December 2019. Four hospitals were compared on two treatments (angiography, do not resuscitate (DNR)) and two outcomes (cerebral performance category (CPC) ≤ 2, in-hospital death). Models for death and CPC were tested with and without coronary angiography and DNR status., Results: 999 patients at hospitals A - D differed (p < 0.05) before multivariable adjustment by age, race, witnessed arrest, dispatch-emergency department (ED) time, TTM, coronary angiography, DNR order, and in-hospital death. Rates of death and CPC ≤ 2 were worse in Hospital A (82.8%, 10%, respectively) compared to others (69.1%, 14.1%). After multivariable adjustment, Hospital A performed angiography less compared to B (OR = 0.17) and was more likely to initiate new DNR status than B (OR = 2.9), C (OR = 16.1), or D (OR = 3.6). CPC ≤ 2 were worse in Hospital A compared to B (OR = 0.27) and D (OR = 0.35). After sensitivity analysis, CPC ≤ 2 odds did not differ for A versus B (OR = 0.58, adjusted for angiography) or D (OR = 0.65, adjusted for DNR). Odds of death, despite angiography and DNR differences, were worse in Hospital A compared to B (OR = 1.87) and D (OR = 1.81)., Conclusion: Differing rates of DNR and coronary angiography was associated with observed disparities in favorable neurologic outcome, but not death, between four Detroit hospitals., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: The 72 nd World Health Assembly has recognised that emergency care at primary health care level is vital for reducing overall mortality and disability. The system of emergency care at this level is affected by various external factors. Little is known about these factors and how they shape the experiences of health care practitioners dealing with medical emergencies in Primary Health Care (PHC) settings. The objective of the study was to explore the experiences of health care practitioners in dealing with emergencies in PHC facilities in the Gauteng province of South Africa., Methods: A qualitative formative evaluation approach was used. Data were collected using semi structured interviews and analysed using qualitative content analysis to describe the experiences of health care practitioners dealing with emergencies at a primary health care level. Participants included health care practitioners from various levels of the district health system., Results: Major themes that emerged explored challenges faced by health care practitioners, the referral system and influential policy such as the ideal clinic movement., Competing Interests: The authors declared no conflicts of interest., (© 2022 The Authors. Published by Elsevier B.V. on behalf of African Federation for Emergency Medicine.)

Objective: Evaluating the usefulness of a chat bot as an assistant during CPR care by laypersons., Methods: Twenty-one university graduates and university students naive in basic life support participated in this quasi-experimental simulation pilot trial. A version beta chatbot was designed to guide potential bystanders who need help in caring for cardiac arrest victims. Through a Question-Answering (Q&A) flowchart, the chatbot uses Voice Recognition Techniques to transform the user's audio into text. After the transformation, it generates the answer to provide the necessary help through machine and deep learning algorithms. A simulation test with a Laerdal Little Anne manikin was performed. Participants initiated the chatbot, which guided them through the recognition of a cardiac arrest event. After recognizing the cardiac arrest, the chatbot indicated the start of chest compressions for 2 min. Evaluation of the cardiac arrest recognition sequence was done via a checklist and the quality of CPR was collected with the Laerdal Instructor App., Results: 91% of participants were able to perform the entire sequence correctly. All participants checked the safety of the scene and made sure to call 112. 62% place their hands on the correct compression point. A media time of 158 s (IQR: 146-189) was needed for the whole process. 33% of participants achieved high-quality CPR with a median of 60% in QCPR (IQR: 9-86). Compression depth had a median of 42 mm (IQR: 33-53) and compression rate had a median of 100 compressions/min (IQR: 97-100)., Conclusion: The use of a voice assistant could be useful for people with no previous training to perform de out-of-hospital cardiac arrest recognition sequence. Chatbot was able to guide all participants to call 112 and to perform continuous chest compressions. The first version of the chatbot for potential bystanders naive in basic life support needs to be further developed to reduce response times and be more effective in giving feedback on chest compressions., Competing Interests: Declaration of Competing Interest All the authors declare that there is no conflict of interest., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

France and Canada prehospital systems and care delivery in out-of-hospital cardiac arrests (OHCAs) show substantial differences. This article aims to describe the rationale, design, implementation and expected research implications of the international, population-based, France-Canada registry for OHCAs, namely ReACanROC, which is built from the merging of two nation-wide, population-based, Utstein-style prospectively implemented registries for OHCAs attended to by emergency medical services. Under the supervision of an international steering committee and research network, the ReACanROC dataset will be used to run in-depth analyses on the differences in organisational, practical and geographic predictors of survival after OHCA between France and Canada. ReACanROC is the first Europe-North America registry ever created to meet this goal. To date, it covers close to 80 million people over the two countries, and includes approximately 200 000 cases over a 10-year period., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

The Objective Structured Clinical Exam (OSCE) is an assessment tool used as a reliable method for clinical competence evaluation of students. This paper presents an investigation focused on the chain of survival, its related exploration, management, and technical skills, and how Virtual Reality (VR) can be used for the creation of immersive environments capable of evaluating students' performance while applying the correct protocols. In particular, the Cardiopulmonary Resuscitation (CPR) procedure is studied as an essential step in the development of the chain of survival. The paper also aims to highlight the limitations of traditional methods using mechanical mannequins and the benefits of the new approaches that involve the students in virtual, immersive, and dynamic environments. Furthermore, an immersive VR station is presented as a new technique for assessing CPR performance through objective data collection and posterior evaluation. A usability test was carried out with 33 clinicians and OSCE evaluators to test the viability of the presented scenario, reproducing conditions of a real examination. Results suggest that the environment is intuitive, quick, and easy to learn and could be used in clinical practice to improve CPR performance and OSCE evaluation.

Background: Virtual reality (VR) is a computer-generated simulation technique which yields plenty of benefits and its application in medical education is growing. This study explored the effectiveness of a VR Basic Life Support (BLS) training compared to a web-based training during the COVID-19 pandemic, in which face-to-face trainings were disrupted or reduced., Methods: This randomised, double-blinded, controlled study, enrolled 1 st year medical students. The control group took part in web-based BLS training, the intervention group received an additional individual VR BLS training. The primary endpoint was the no-flow time-an indicator for the quality of BLS-, assessed during a structural clinical examination, in which also the overall quality of BLS (secondary outcome) was rated. The tertiary outcome was the learning gain of the undergraduates, assessed with a comparative self-assessment (CSA)., Results: Data from 88 undergraduates (n = 46 intervention- and n = 42 control group) were analysed. The intervention group had a significant lower no-flow time (p = .009) with a difference between the two groups of 28% (95%-CI [8%;43%]). The overall BLS performance of the intervention group was also significantly better than the control group with a mean difference of 15.44 points (95%-CI [21.049.83]), p < .001. In the CSA the undergraduates of the intervention group reported a significant higher learning gain., Conclusion: VR proved to be effective in enhancing process quality of BLS, therefore, the integration of VR into resuscitation trainings should be considered. Further research needs to explore which combination of instructional designs leads to deliberate practice and mastery learning of BLS., (© 2022. The Author(s).)

Background: The impact of the COVID-19 pandemic on bystander cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) is unclear. This study aimed to investigate whether rates of bystander CPR and patient outcomes changed during the initial state of emergency declared in Tokyo for the COVID-19 pandemic., Methods: This retrospective study used data from a population-based database of OHCA maintained by the Tokyo Fire Department. By comparing data from the periods before (18 February to 6 April 2020) and during the declaration of a state of emergency (7 April 2020 to 25 May 2020), we estimated the change in bystander CPR rate, prehospital return of spontaneous circulation, and survival and neurological outcomes 1 month after OHCA, accounting for outcome trends in 2019. We performed a multivariate regression analysis to evaluate the potential mechanisms for associations between the state of emergency and these outcomes., Results: The witnessed arrest rates before and after the declaration periods in 2020 were 42.5% and 45.1%, respectively, compared with 44.1% and 44.7% in the respective corresponding periods in 2019. The difference between the two periods in 2020 was not statistically significant when the trend in 2019 was considered. The bystander CPR rates before and after the declaration periods significantly increased from 34.4% to 43.9% in 2020, an 8.3% increase after adjusting for the trend in 2019. This finding was significant even after adjusting for patient and bystander characteristics and the emergency medical service response. There were no significant differences between the two periods in the other study outcomes., Conclusion: The COVID-19 pandemic was associated with an improvement in the bystander CPR rate in Tokyo, while patient outcomes were maintained. Pandemic-related changes in patient and bystander characteristics do not fully explain the underlying mechanism; there may be other mechanisms through which the community response to public emergency increased during the pandemic., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The city of Freiburg has been among the most affected regions by the COVID-19 pandemic in Germany. In out of hospital cardiac arrest (OHCA) care, all parts of the rescue system were exposed to profound infrastructural changes. We aimed to provide a comprehensive overview of these changes in the resuscitation landscape in the Freiburg region., Methods: Utstein-style quantitative data on OHCA with CPR initiated, occurring in the first pandemic wave between February 27th, 2020 and April 30th, 2020 were compared to the same time periods between 2016 and 2019. Additionally, qualitative changes in the entire rescue system were analyzed and described., Results: Incidence of OHCA with attempted CPR did not significantly increase during the pandemic period (11.1/100.000 inhabitants/63 days vs 10.4/100.000 inhabitants/63 days, p = 1.000). In witnessed cases, bystander-CPR decreased significantly from 57.7% (30/52) to 25% (4/16) (p = 0.043). A severe pre-existing condition (PEC) was documented more often, 66.7% (16/24) vs 38.2% (39/102) there were longer emergency medical services (EMS) response times, more resuscitation attempts terminated on scene, 62.5% (15/24) vs. 34.3% (35/102) and less patients transported to hospital (p = 0.019). Public basic life support courses, an app-based first-responder alarm system, Kids Save Lives activities and a prehospital extracorporeal CPR (eCPR) service were paused during the peak of the pandemic., Conclusion: In our region, bystander CPR in witnessed OHCA cases as well as the number of patients transported to hospital significantly decreased during the first pandemic wave. Several important parts of the resuscitation landscape were paused. The COVID-19 pandemic impedes OHCA care, which leads to additional casualties. Countermeasures should be taken., (© 2022. The Author(s).)

Introduction: In conventional basic life support (c-BLS), a lone rescuer is recommended to start chest compressions (CCs) after activating the emergency medical system. To initiate earlier CCs in lone-rescuer BLS, we designed a modified BLS (m-BLS) sequence in which the lone rescuer commences one-handed CCs while calling for help using a handheld cellular phone with the other free hand. This study aimed to compare the quality of BLS between c-BLS and m-BLS., Methods: This was a simulation study performed with a randomised cross-over controlled trial design. A total of 108 university students were finally enrolled. After training for both c-BLS and m-BLS, participants performed a 3-minute c-BLS or m-BLS on a manikin with a SkillReporter at random cross-over order. The paired mean difference with SE between c-BLS and m-BLS was assessed using paired t-test., Results: The m-BLS had reduced lag time before the initiation of CCs (with a mean estimated paired difference (SE) of -35.0 (90.4) s) (p<0.001). For CC, a significant increase in compression fraction and a higher number of CCs with correct depth were observed in m-BLS (with a mean estimated paired difference (SE) of 16.2% (0.6) and 26.9% (3.3), respectively) (all p<0.001). However, no significant paired difference was observed in the hand position, compression rate and interruption time. For ventilation, the mean tidal volumes did not differ. However, the number of breaths with correct tidal volume was higher in m-BLS than in c-BLS., Conclusion: In simulated lone-rescuer BLS, the m-BLS could deliver significantly earlier CCs than the c-BLS while maintaining high-quality cardiopulmonary resuscitation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

The high incidence of out-of-hospital cardiac arrest refractory to standard resuscitation protocols, despite precompetitive screening, demonstrated the need for a prehospital team to provide an effective system for life support and resuscitation at the Volleyball Men's World Championship. The evolution of mechanical circulatory support suggests that current advanced cardiovascular life support protocols no longer represent the highest standard of care at competitive sporting events with large spectator numbers. Extracorporeal life support (ECLS) improves resuscitation strategies and offers a rescue therapy for refractory cardiac arrest that can no longer be ignored. We present our operational experience of an out-of-hospital ECLS cardiopulmonary resuscitation team at an international sporting event., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Community first responders (CFR) improve survival in out-of-hospital cardiac arrest (OHCA) but are often hampered by limited availability of public access defibrillation. Unmanned aerial systems (UAS) delivering automated external defibrillators (AED) directly to an OHCA site could help overcome this. We evaluated the feasibility of integrating UAS into the chain of survival in rural Northeast Germany., Methods: This simulation study explored UAS-AED delivery combined with a smartphone-based CFR dispatch. Five OHCA locations (A-E) were randomly selected. We routed a flight corridor to each of these sites from a corresponding UAS base; 50 OHCA scenarios with 10 flights per corridor were scheduled. All steps were accurately simulated, from a bystander finding the patient, making an emergency call, conducting dispatcher-assisted cardiopulmonary resuscitation, and simultaneous CFR plus UAS deployment, to the bystander and CFR interacting with UAS and AED. This process was time-tracked and video-recorded until defibrillation., Results: We performed 46 OHCA simulations. Missions were flown autonomously but needed pilot assistance during landing. Distances (km) and average time intervals from alert to defibrillation (t d in min:sec ± SD) were 0.4 (6:02 ± 0:56), 2.29 (6:53 ± 0:19), 4.0 (8:54 ± 0:25), 7.43 (14:51 ± 1:055), and 9.79 (15:51 ± 1:16) for routes A to E, respectively. All participants were able to retrieve the AED within seconds after UAS landing and interacted safely with the UAS and AED., Conclusions: Integrating airborne AED delivery into the chain of survival appeared feasible and safe but remains an experimental technology. Linking this with CFR potentially improves the availability of early public-access defibrillation, particularly in rural regions., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

Aims: A short awareness time interval (ATI, time from witnessing the arrest to calling for help) and bystander cardiopulmonary resuscitation (CPR) are important factors affecting neurological recovery after out-of-hospital cardiac arrest (OHCA). This study investigated the association of the location of OHCA with the length of ATI and bystander CPR., Methods: This population-based observational study used the nationwide Korea OHCA database and included all adults with layperson-witnessed OHCA with presumed cardiac aetiology between 2013 and 2017. The exposure was the location of OHCA (public places, private housing and nursing facilities). The primary outcome was short ATI, defined as <4 min from witnessing to calling for emergency medical service (EMS). The secondary outcome was the frequency of provision of bystander CPR. Multivariable logistic regression analysis was performed to evaluate the association of location of OHCA with study outcomes., Results: Of 30 373 eligible OHCAs, 66.6% occurred in private housing, 24.0% occurred in public places and 9.4% occurred in nursing facilities. In 67.3% of the cases, EMS was activated within 4 min of collapse, most frequently in public places (public places 77.0%, private housing 64.2% and nursing facilities 64.8%; p<0.01). The overall rate of bystander CPR was 65.5% with highest in nursing facilities (77.0%), followed by public places (70.1%) and private housing 62.3%; p<0.01). Compared with public places, the adjusted ORs (AORs) (95% CIs) for a short ATI were 0.58 (0.54 to 0.62) in private housing and 0.62 (0.56 to 0.69) in nursing facilities. The AORs (95% CIs) for bystander CPR were 0.75 (0.71 to 0.80) in private housing and 1.57 (1.41 to 1.75) in nursing facilities., Conclusion: OHCAs in private housing and nursing facilities were less likely to have immediate EMS activation after collapse than in public places. A public education is needed to increase the awareness of necessity of prompt EMS activation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

The Chain of Survival in Industrial Emergencies and Disasters is similar to the cardiac arrest chain of survival of the American Heart Association (AHA) and the trauma chain of survival. It is a sequence of five inter-linked rings, which when practiced, decreases the mortality and morbidity in the concerned population. The first ring is Early Prevention, which should be a combined effort of healthcare professionals and industrial authorities. The second ring is Early Recognition. Industrial workers and surrounding communities should be equally trained in hazard and risk analysis along with vulnerability assessment. The third ring is Access to Care by the Early Response System, involving a universal emergency response number and early intervention by on-site trained medical professionals. This ring emphasizes the importance of a link with the surrounding communities, as they are the first responders and the front-line victims. The fourth ring is Early Advanced Care by EMS for transportation to hospitals or by Emergency Department personnel in referral hospitals. The fifth and the last ring is Early Rehabilitation, which includes integrated post emergency care, overall rehabilitation and early return to work. The key to successful implementation of Chain of Survival is to have identified components of care, training and quality monitoring. When practiced diligently, this could help prevent industrial disasters, and mitigate their harmful effects on occurrence.

Background: High-quality Basic Life Support (BLS), the first step in the Utstein formula for survival, needs effective education for all kinds of population groups. The feasibility of BLS courses for refugees is not well investigated yet., Methods: We conducted BLS courses including automated external defibrillator (AED) training for refugees in Austria from 2016 to 2019. Pre-course and after course attitudes and knowledge towards cardiopulmonary resuscitation (CPR) were assessed via questionnaires in the individuals' native languages, validated by native speaker interpreters., Results: We included 147 participants (66% male; 22 [17-34] years; 28% <18 years) from 19 countries (74% from the Middle East). While the availability of BLS courses in the participants' home countries was low (37%), we noted increased awareness towards CPR and AED use after our courses. Willingness to perform CPR increased from 25% to 99%. A positive impact on the participants' perception of integration into their new environment was noted after CPR training. Higher level of education, male gender, age <18 years and past traumatizing experiences positively affected willingness or performance of CPR., Conclusion: BLS education for refugees is feasible and increases their willingness to perform CPR in emergency situations, with the potential to improve survival after cardiac arrest. Individuals with either past traumatizing experiences, higher education or those <18 years might be eligible for advanced life support education. Interestingly, these BLS courses bear the potential to foster resilience and integration. Therefore, CPR education for refuge should be generally offered and further evaluated., (© 2021 The Authors. European Journal of Clinical Investigation published by John Wiley & Sons Ltd on behalf of Stichting European Society for Clinical Investigation Journal Foundation.)

Background: Evidence to support a better cardiopulmonary resuscitation method between standard vs. continuous chest compression (STD-CPR vs. CCC-CPR) is lacking., Materials and Methods: Our systematic review followed PRISMA guidelines. We searched PubMed, ScienceDirect, EBSCOhost, and ProQuest database from 1985 to 26 September 2019 restricted to randomized controlled trial, human study, and English articles. Quality assessment of between-study heterogeneity and a trial sequential analysis (TSA) were conducted. We estimated overall significance with 80% power and adjusted Z values thresholds using O'Brien-Fleming α‑spending function. Required information size with 21% relative risk using the estimation between-group incidences provided from the median rate across trials was determined. Inconclusive TSA result will lead to size estimation of future RCT. Quality of evidence was analyzed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) Handbook and TSA., Results: Based on three trials in OHCA with dispatcher-guided and bystander-initiated CPR, our meta-analysis favors CCC-CPR for survival to hospital discharge, compared to STD-CPR (RR [Risk Ratio] = 1.21[1.01-1.46], 95% CI, p = 0.68, I 2  = 0). However, current meta-analyses with 3031 patients appeared to be inconclusive. There is a significant risk of type 1 error and therefore, results are potentially false positive. It is estimated that a minimal of 4331 patients needed to deem a conclusive result and a total of 5894 patients with similar risk profile required to stabilize statistic results in future trials. Quality of evidence is downgraded to moderate due to serious imprecision based on TSA., Conclusion: Based on these analyses, evidence is inadequate to conclude the superiority of one CPR method over the other. Further trials with larger numbers of patients are needed to deem a conclusive and stable meta-analysis., (© 2020. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Incidence of in-hospital cardiac arrest is reported to be 0.8 to 4.6 per 1,000 patient admissions. Patient survival to hospital discharge with favourable functional and neurological status is around 21-30%. The Bern University Hospital is a tertiary medical centre in Switzerland with a cardiac arrest team that is available 24 h per day, 7 days per week. Due to lack of central documentation of cardiac arrest team interventions, the incidence, outcomes and survival rates of cardiac arrests in the hospital are unknown. Our aim was to record all cardiac arrest team interventions over 1 year, and to analyse the outcome and survival rates of adult patients after in-hospital cardiac arrests., Methods: We conducted a prospective single-centre observational study that recorded all adult in-hospital cardiac arrest team interventions over 1 year, using an Utstein-style case report form. The primary outcome was 30-day survival after in-hospital cardiac arrest. Secondary outcomes were return of spontaneous circulation, neurological status (after return of spontaneous circulation, after 24 h, after 30 days, after 1 and 5 years), according to the Glasgow Outcomes Scale, and functional status at 30 days and 1 year, according to the Short-form-12 Health Survey., Results: The cardiac arrest team had 146 interventions over the study year, which included 60 non-life-threatening alarms (41.1%). The remaining 86 (58.9%) acute life-threatening situations included 68 (79.1%) as patients with cardiac arrest. The mean age of these cardiac arrest patients was 68 ± 13 years, with a male predominance (51/68; 75.0%). Return of spontaneous circulation was recorded in 49 patients (72.1%). Over one-third of the cardiac arrest patients (27/68) were alive after 30 days with favourable neurological outcome. The patients who survived the first year lived also to 5 years after the event with favourable neurological and functional status., Conclusions: The in-hospital cardiac arrest incidence on a large tertiary Swiss university hospital was 1.56 per 1000 patient admissions. After a cardiac arrest, about a third of the patients survived to 5 years with favourable neurological and functional status. Alarms unrelated to life-threatening situations are common and need to be taken into count within a low-threshold alarming system., Trial Registration: The trial was registered in clinicaltrials.gov (NCT02746640)., (© 2021. The Author(s).)

Competing Interests: Competing interests: None declared.

Purpose: To validate the content and adequacy of the «Rescube» training material that includes adapted information from the chain of survival., Material and Methods: The study included three steps: (i)material development by 7 experts, following Delphi method; (ii)assessment of training material by 11 experts by means of a Likert score and calculation of content validity; and (iii)pilot study in two groups of 5 to 8years-old: Rescube group (GR; n=60) and Traditional group (GT; n=60). GR was trained with Rescube and a Teddy bear, while GT was traditionally trained with a pediatric manikin. Participants were individually assessed at baseline, and one week and one month after training., Results: All content validity indexes calculated are above the recommended cut-off for analysis with more than 9 experts (≥0,80). Children's learning results were positive, with percentages equal or higher than 80% in all registered variables at the first (one week) evaluation and equal or higher than 67% when evaluated one month after training. No significant differences were detected between groups., Conclusion: The Rescube training tool based on infantile pictures is valid and useful to train young schoolchildren in the chain of survival., (Copyright © 2021 Asociación Española de Pediatría. Publicado por Elsevier España, S.L.U. All rights reserved.)

Aim: Resuscitation from out of hospital cardiac arrest (OHCA) requires success across the entire chain of survival. Using a large state-wide registry, we characterized variation in clinical outcomes at hospital discharge in Michigan hospitals., Methods: We utilized the Michigan Cardiac Arrest Registry to Enhance Survival (CARES) and included adult OHCA subjects with return of spontaneous circulation (ROSC) from 2014 - 2017 that survived to hospital admission. 39 Michigan hospitals were included which managed >30 cases during the study period. Multilevel logistic regression, controlling for both subject characteristics and clustering of subjects within hospitals, assessed variation across hospitals in survival to hospital discharge and survival with cerebral performance category (CPC 1-2)., Results: There were 5,486 CARES subjects that survived to hospital admission, and 4,690 met inclusion for analysis. Of 39 included hospitals, median survival to discharge was 31.3% (range 12.5%-46.7%) and median survival to discharge with CPC 1-2 was 25.0% (range 5.2%-42.2%). We identified 12-fold variation in the utilization of TTM by hospital (median 47.9%, range 6.7%-80.0%) for all admitted subjects. Similarly, there was nearly an eight-fold variation in LHC for all post-arrest subjects (median 22.1%, range 5.4%-42.2%). In multivariable analyses, median adjusted survival to discharge was 26.9% (range 18.1%-42.1%) and median adjusted survival to discharge with CPC 1-2 was 21.3% (range 9.6%-32.1%)., Conclusion: We observed substantial variation in clinical outcomes at discharge between Michigan hospitals, including a four-fold range of survival and eight-fold range of survival with CPC 1-2. This variation was ameliorated but still persisted in adjusted modeling. Variation in post arrest survival by hospital was not fully explained by available covariates, which suggests the possibility of improving post-arrest clinical outcomes at some hospitals via quality improvement activities., (Copyright © 2020 Elsevier B.V. All rights reserved.)

An update of the first description of quality indicators and structural requirements for Cardiac Arrest Centers from 2017 based on first experiences and certifications is presented. Criteria were adjusted, substantiated and in some parts redefined for feasibility in everyday clinical use., (© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2021.)

Background: Most resuscitation guidelines have recommendations regarding maximum delay times from collapse to calling for the rescue team and initiation of treatment following cardiac arrest. The aim of the study was to investigate the association between adherence to guidelines for cardiopulmonary resuscitation (CPR) after in-hospital cardiac arrest (IHCA) and survival with a focus on delay to treatment., Methods: We used the Swedish Registry for CPR to study 3212 patients with a shockable rhythm and 9113 patients with non-shockable rhythm from January 1, 2008 to December 31, 2017. Adult patients older than or equal to 18 years with a witnessed IHCA where resuscitation was initiated were included. We assessed trends in adherence to guidelines and their associations with 30-day survival and neurological function. Adherence to guidelines was defined as follows: time from collapse to calling for the rescue team and CPR within 1 min for non-shockable rhythms. For shockable rhythms, adherence was defined as the time from collapse to calling for the rescue team and CPR within 1 min and defibrillation within 3 min., Results: In patients with a shockable rhythm, the 30-day survival for those treated according to guidelines was 66.1%, as compared to 46.5% among those not treated according to guidelines on one or more parameters, adjusted odds ratio 1.84 (95% CI 1.52-2.22). Among patients with a non-shockable rhythm the 30-day survival for those treated according to guidelines was 22.8%, as compared to 16.0% among those not treated according to guidelines on one or more parameters, adjusted odds ratio 1.43 (95% CI 1.24-1.65). Neurological function (cerebral performance category 1-2) among survivors was better among patients treated in accordance with guidelines for both shockable (95.7% vs 91.1%, <0.001) and non-shockable rhythms (91.0% vs 85.5%, p < 0.008). Adherence to the Swedish guidelines for CPR increased slightly 2008-2017., Conclusions: Adherence to guidelines was associated with increased probability of survival and improved neurological function in patients with a shockable and non-shockable rhythm, respectively. Increased adherence to guidelines could increase cardiac arrest survival., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Colorectal cancer is a major cause of morbidity and mortality, and screening has been shown to reduce morbidity and mortality. This review highlights pertinent aspects of adherence to screening including the various options available and key concepts to consider in any systematic program. Persistent adherence, which is key to an efficacious screening program, is the compliance with repeated screening tests over a period of time. A "chain of survival" mindset emphasizes the stepwise, sequential and persistent approach to screening and is a helpful concept to drive the message of persistent adherence. A framework for the patient and physician interactions that support screening intervention is examined, and various factors that impact both patient and physician adoption and screening modality recommendations are reviewed. While systems-based approaches to screening have great utility in automation and monitoring in a surveillance program, some emerging data suggests that the human touch is still an essential driver for active participation in these programs. Finally, the proportion of time concept is discussed as a useful index for monitoring persistent adherence in both individuals and populations.

Background: In 2010, the American Heart Association recommended that postcardiac arrest care should be included in the chain of survival to reduce permanent neurological damage, improve quality of life, and reduce health care expenses of postcardiac arrest care., Objectives: To investigate post-in-hospital cardiac arrest (IHCA) survival prior to and after modification of the chain of survival in 2010, with subgroup analyses per age and concomitant coronary heart disease (CHD)., Methods: We retrospectively searched the National Health Insurance Research Database for the 2007-2015 period to collect case data coded as "427.41" or "427.5" per International Classification of Disease Clinical Modification, Ninth revision codes and analyzed the data with SPSS v22.0., Results: The 1-day survival rate in the 2011-2015 period was 2% higher than that in the 2007-2010 period (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.01-1.04). Moreover, in the 2011-2015 period, the survival-to-discharge rate was increased by 1% in patients under 65 years (OR 1.01, 95% CI 1.00-1.02) and 1% in CHD patients (OR 1.01, 95% CI 1.01-1.02) compared with that in the 2007-2010 period., Conclusion: For patients with IHCA, the overall short-term survival improved significantly after modification of the chain of survival. Younger patients and patients with CHD had better long-term survival., (Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: Global and national trends of out-of-hospital cardiac arrest (OHCA) have been examined; however, geographic variation and socioeconomic disparities of OHCA outcomes in the community setting are less understood. We developed and tested a replicable, community-oriented assessment strategy aimed to identify spatial variations in OHCA outcomes using socioeconomic, prehospital, and in-hospital factors. Methods: Emergency medical service (EMS) records of adult, non-traumatic OHCA within Alachua County, FL (2012-2017) were retrospectively reviewed and matched to corresponding medical records at the University of Florida (UF). Incidence of cardiac arrest was geocoded to census tracts and connected to U.S. census socioeconomic attribute data. Primary outcomes include survival to emergency department (ED), hospital admission, discharge, and discharge to home. Multilevel mixed-effects logistic regression models were developed to assess sub-county geographic variance, probabilities of survival, and prehospital risk factors. Getis-Ord Gi statistic and Moran's I-test was applied to assess spatial clustering in outcome survival rates. Results: Of the 1562 OHCA cases extracted from EMS records, 1,335 (85.5%) were included with 372 transported to study site. Predicted probability of survival to ED was 57.0% (95CI: 51.3-62.3%). Of transported cases to study site ED, predicted probabilities of survival was to 41.7% (95CI: 36.1-47.6%) for hospital admission, 16.1% (95CI: 10.7-23.5%) for hospital discharge, and 7.1% (95CI: 3.7-13.3%) for home discharge. Census tracts accounted for significant variability in survival to ED (p < 0.001), discharge (p = 0.031), and home discharge outcomes (p = 0.036). There was no significant geographic variation in survival to admission outcome. Neighborhood-level factors significantly improved model fit for survival to ED, discharge, and discharge home outcomes. Multiple modifiable patient- and neighborhood-level variables of interest were identified, including rural-urban differences. Conclusion: We identified important geographic disparities that exist in OHCA outcomes at the community level. By using a replicable schematic, this variation can be explained through community-oriented modifiable socioeconomic and prehospital factors.

The effect of post-cardiac arrest care in children with out-of-hospital cardiac arrest (OHCA) has not been adequately established, and the long-term outcome after pediatric OHCA has not been sufficiently investigated. We describe here detailed in-hospital characteristics, actual management, and survival, including neurological status, 90 days after OHCA occurrence in children with OHCA transported to critical care medical centers (CCMCs).We analyzed the database of the Comprehensive Registry of Intensive Care for OHCA Survival (CRITICAL) study, which is a multicenter, prospective observational data registry designed to accumulate both pre- and in-hospital data on OHCA treatments. We enrolled all consecutive pediatric patients aged <18 years who had an OHCA and for whom resuscitation was attempted and who were transported to CCMCs between 2012 and 2016.A total of 263 pediatric patients with OHCA were enrolled. The average age of the patients was 6.3 years, 38.0% were aged < 1 year, and 60.8% were male. After hospital arrival, 4.9% of these pediatric patients received defibrillation; 1.9%, extracorporeal life support; 6.5%, target temperature management; and 88.2% adrenaline administration. The proportions of patients with 90-day survival and a pediatric cerebral performance category (PCPC) score of 1 or 2 were 6.1% and 1.9%, respectively. The proportion of patients with a PCPC score of 1 or 2 at 90 days after OHCA occurrence did not significantly improve during the study period.The proportion of pediatric patients with a 90-day PCPC score of 1 or 2 transported to CCMCs was extremely low, and no significant improvements were observed during the study period.

Background: Using a mobile virtual reality (VR) platform to heighten realism for cardiopulmonary resuscitation (CPR) training has the potential to improve bystander response., Objectives: We examined whether using a VR mobile application (mApp) for CPR training would improve bystander response compared with a standard mApp CPR training., Methods: We randomized lay bystanders to either our intervention arm (VR mApp) or our control arm (mApp). During a post-intervention skills test, we collected bystander response data (call 911, perform CPR, ask for an automated external defibrillator (AED)), along with CPR quality (chest compression (CC) rate and depth). Wilcox rank sum was used to analyze CC rate and CC depth as they were not normally distributed; Pearson's Chi-square was used to analyze Chain of Survival variables., Results: Between 3/2018 and 9/2018, 105 subjects were enrolled: 52 VR mApp and 53 mApp. Mean age was 46 ± 16 years, 34% were female, 59% were Black, and 17% were currently CPR trained (≤2 years). Bystander response was significantly higher in the VR mApp arm: called 911 (82% vs 58%, p = 0.007) and asked for an AED (57% vs 28%, p = 0.003). However there was no difference in CPR performed (98% vs 98%, p = NS) and the application of the AED (90% vs 93%, p = NS). When comparing the VR mApp to the mApp, mean CC rate was 104 ± 42 cpm vs 112 ± 30 cpm (p = NS), and mean CC depth was 38 ± 15 mm vs 44 ± 13 mm (p = 0.05)., Conclusion: The use of the VR mApp significantly increased the likelihood of calling 911 and asking for an AED, however, CC depth was decreased., (Copyright © 2019 Elsevier B.V. All rights reserved.)

The chain of survival aims to demonstrate the interrelationship between key stages of resuscitation and emphasises the need for all links to be effective in order to optimise the chances of survival. The contribution of each of the four links diminishes rapidly as patients succumb at each stage and the actual attrition rate results in rapidly decreasing numbers of patients progressing along the chain. This revised representation adjusts the area of each link in order to graphically represent the flow of patients through the chain. Greatest benefit in improving outcome will be achieved by focussing on improving care at links in the chain where there is the greatest number of patients., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Out of hospital cardiac arrest affects 350,000 Americans yearly and is associated with a high mortality rate. Improving survival rates in this population rests on the prompt and effective implementation of four key principles. These include 1) early recognition of cardiac arrest 2) early use of chest compressions 3) early defibrillation, which in turn emphasizes the importance of public access defibrillation programs and potential for drone technology to allow for early defibrillation in private or rural settings 4) early and aggressive post-arrest care including the consideration of therapeutic hypothermia, early coronary angiography +/- percutaneous coronary intervention and a hyper-invasive approach to out-of-hospital refractory cardiac arrest., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.)

Despite the best efforts of event producers and on-site medical teams, there are sometimes serious illnesses, life-threatening injuries, and fatalities related to music festival attendance. Producers, clinicians, and researchers are actively seeking ways to reduce the mortality and morbidity associated with these events. After analyzing the available literature on music festival health and safety, several major themes emerged. Principally, stakeholder groups planning in isolation from one another (ie, in silos) create fragmentation, gaps, and overlap in plans for major planned events (MPEs). The authors hypothesized that one approach to minimizing this fragmentation may be to create a framework to "connect the dots," or join together the many silos of professionals responsible for safety, security, health, and emergency planning at MPEs. Adapted from the well-established literature regarding the management of cardiac arrests, both in and out of hospital, the "chain of survival" concept is applied to the disparate groups providing services that support event safety in the context of music festivals. The authors propose this framework for describing, understanding, coordinating and planning around the integration of safety, security, health, and emergency service for events. The adapted Event Chain of Survival contains six interdependent links, including: (1) event producers; (2) police and security; (3) festival health; (4) on-site medical services; (5) ambulance services; and (6) off-site medical services. The authors argue that adapting and applying this framework in the context of MPEs in general, and music festivals specifically, has the potential to break down the current disconnected approach to event safety, security, health, and emergency planning. It offers a means of shifting the focus from a purely reactive stance to a more proactive, collaborative, and integrated approach. Improving health outcomes for music festival attendees, reducing gaps in planning, promoting consistency, and improving efficiency by reducing duplication of services will ultimately require coordination and collaboration from the beginning of event production to post-event reporting. Lund A , Turris SA . The Event Chain of Survival in the context of music festivals: a framework for improving outcomes at major planned events. Prehosp Disaster Med. 2017;32(4):437-443.

Aim of the Study: Bystanders can play an important role in the event of sudden injury or illness. Our aim was to evaluate the effects of a 3-day first aid course for all primary school age groups (7-14 years old)., Methods: 582 school children were involved in the study. Training consisted of three sessions with transfer of theoretical knowledge and practical skills about first aid. The following most urgent situations were addressed in our study: adult basic life support (BLS), using an automated external defibrillator (AED), handling an unconscious patient, managing bleeding and calling the ambulance. Data collection was made with a questionnaire developed for the study and observation. Students were tested before, immediately after and 4 months after training. Results were considered significant in case of p<0.05., Results: Prior to training there was a low level of knowledge and skills on BLS, management of the unconscious patient, use of an AED and management of bleeding. Knowledge and skills improved significantly in all of these categories (p<0.01) and remained significantly higher than the pre-test level at 4 months after training (p<0.01). Younger children overall performed less well than older children, but significantly improved over the pre-test level both immediately and 4 months after training (p<0.01). Prior first aid training was associated with knowledge of the correct ambulance number (p=0.015) and management of bleeding (p=0.041). Prior to training, age was associated with pre-test knowledge and skills of all topics (p<0.01); after training, it was only associated with AED use (p<0.001). There was a significant correlation between the depth of chest compression and children's age, weight, height and body mass index (p<0.001). Ventilation depended on the same factors (p<0.001)., Conclusion: Children aged 7-14 years are able to perform basic life-saving skills. Knowledge retention after 4 months is good for skills, but thinking in algorithms is difficult for these children., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Sudden cardiac death (SCD) is a major issue of public health with more than 350,000 deaths per year in the United States, accounting for almost half of cardiovascular mortality. Despite major investments in both prevention and resuscitation, SCD mortality remains high, highlighting the need for a novel approach to reduce SCD burden. We hereby propose a new approach - near-term prevention - that is based on Anticipation, aiming to ensure that resuscitation will be initiated early enough after SCD, or even that prophylactic therapy will be initiated in this well targeted population for preventing SCD occurrence., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Introduction: Maintaining the standard two-handed chest compression is difficult in high-speed ambulances in rural areas., Methods: A retrospective, video-based, observational study was conducted from June to September 2013 in Nantou, a rural county of central Taiwan, to evaluate the chest compression fraction in an ambulance carriage during the travel from the scene to the hospital. The chest compression fraction was calculated as the chest compression time period divided by the ambulance travelling time period; the one-handed and two-handed chest compression fractions were also calculated., Results: During the 4-month study period, a total of 102 videos that were recorded in an ambulance carriage were reviewed, including 97 cases of manual chest compressions. When there was only one emergency medical technician (EMT) in the carriage, the combined chest compression fraction was 50.6±20.7%; when there were two EMTs, the fraction was 58.3±16.0% and the fraction was 58.3±21.0% in a three-EMT scenario (p=0.221). Moreover, in the carriage, EMTs usually performed one-handed chest compressions., Conclusions: The chest compression fraction was low for patients with out-of-hospital cardiac arrest in a moving ambulance, irrespective of the number of providers. Reasons for this observation, as well as the effectiveness of the one-handed chest compression require further evaluation., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: The chain of survival is a set of most important factors affecting survival after an out-of-hospital cardiac arrest (OHCA). Recognising the difficulties in applying the chain is the key to improving outcomes. Early return of spontaneous circulation (ROSC) after a cardiac arrest is a fundamental factor for patient survival., Aim: To assess the degree to which the location of OHCA affects ROSC during resuscitation efforts., Methods: Emergency medical service (EMS) teams filled cardiac arrest forms based on standard (Utstein) guidelines. The registry covered data from January 2013 to May 2014 collected over the area of 23,706 km2 with the population density of 90 persons/km2. This constitutes 7.6% of the area of Poland. The average population density in Poland is 123 persons/km2., Results: Over the time period covered by the study, 5185 cases of OHCA were reported. Resuscitation was attempted in 2415 (46.6%) cases. ROSC was achieved in 736 (30.48%) cases, including 374 (32.13%) cases in urban areas and 362 (28.94%) cases in rural areas. This difference was not statistically significant. Compared to urban areas, event witnesses in rural areas were more likely to perform bystander resuscitation and receive instructions from the EMS dispatchers. In the whole study group, cardiac disorders were the most common underlying cause of cardiac arrest (70.35%). The median time of ambulance arrival to the scene was significantly shorter in urban areas compared to rural areas (median time 6 min and 12 min, respectively)., Conclusions: No significant relation was found between the location of OHCA and ROSC despite the fact that the time to ambulance arrival was significantly shorter in urban areas. In rural areas, resuscitation was more frequently initiated by the event witnesses. Both in urban and rural areas, OHCA was most commonly due to cardiac causes, and the initial recorded cardiac rhythm was a non-shockable one.

Background and Methods: Do emergency teams (ETs) consider the underlying causes of in-hospital cardiac arrest (IHCA) during advanced life support (ALS)? In a 4.5-year prospective observational study, an aetiology study group examined 302 episodes of IHCA. The purpose was to investigate the causes and cause-related survival and to evaluate whether these causes were recognised by the ETs., Results: In 258 (85%) episodes, the cause of IHCA was reliably determined. The cause was correctly recognised by the ET in 198 of 302 episodes (66%). In the majority of episodes, cardiac causes (156, 60%) or hypoxic causes (51, 20%) were present. The cause-related survival was 30% for cardiac aetiology and 37% for hypoxic aetiology. The initial cardiac rhythm was pulseless electrical activity (PEA) in 144 episodes (48%) followed by asystole in 70 episodes (23%) and combined ventricular fibrillation/ventricular tachycardia (VF/VT) in 83 episodes (27%). Seventy-one patients (25%) survived to hospital discharge. The median delay to cardiopulmonary resuscitation (CPR) was 1min (inter-quartile range 0-1min)., Conclusions: Various cardiac and hypoxic aetiologies dominated. In two-thirds of IHCA episodes, the underlying cause was correctly identified by the ET, i.e. according to the findings of the aetiology study group., (Copyright © 2014 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.)

Aim: The purpose of this study was to assess the outcome of out-of-hospital cardiac arrests (OHCAs) in Beijing, China., Methods: In this prospective study, data were collected according to the Utstein style on all cases of OHCA that occurred between January and December 2012 in urban areas covered by Beijing Emergency Medical Services (EMS). The cases were followed-up for 1 year., Results: Out of the 9897 OHCAs recorded, cardiopulmonary resuscitation (CPR) was initiated in 2421 patients (24.4%). Among the CPR-receivers (n=2421), 1804 patients (74.5%) had collapsed at home, while 375 patients (15.5%) at a public place. The average time interval from call to EMS arrival at the collapse location was 16 min (range, 4-43 min). Of the 1693 OHCA cases with cardiac aetiology, 1246 cases (73.6%) were witnessed, and basic CPR was performed by bystanders before arrival of the EMS personnel in 193 patients (11.4%). Of the OHCAs with cardiac aetiology, 1054 patients (62.3%) had asystole, 131 patients (7.7%) had shockable rhythms, restoration of spontaneous circulation was achieved in 85 patients (5.0%), 71 patients (4.2%) were admitted to the hospital alive, and of the 22 patients (1.3%) who were discharged alive, 17 patients (1%) had good neurological outcomes. At 1 year post-OHCA, 17 patients were alive., Conclusion: In the urban areas of Beijing with EMS services, survival rate after OHCA was unsatisfactory. Improvements are required in every link of the 'chain of survival'., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

All nations would benefit from a simple, clear Drowning Chain of Survival. In high income nations this tool will refine prevention and the call for action. In low and middle income nations this tool is a guide for policy making, resource allocation and priority setting in drowning prevention. A best evidence approach was utilized to create a universal Drowning Chain of Survival. Education on how to prevent drowning and to how react when a drowning incident occurs has not always been guided by good levels of evidence, or high levels of specialized training in drowning process recognition and management. The Drowning Chain of Survival refers to a series of steps that when enacted, attempts to reduce mortality associated with drowning and attempted aquatic rescue. The term "chain of survival" has provided a useful metaphor for the elements of the emergency cardiac care system for sudden cardiac arrest, however interventions and patient management in drowning involves principles and actions that are specific to these situations. The result is a unique and universal Drowning Chain of Survival comprised of five links guiding the important life-saving steps for lay and professional rescuers. This may significantly improve chances of prevention, survival and recovery from drowning. The steps of the chain are: Prevent drowning, Recognize distress, Provide flotation, Remove from water, and Provide care as needed., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)