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Background: The World Health Organization's endorsement of the "Kids save lives" statement fosters the implementation of cardiopulmonary resuscitation (CPR) training for school children worldwide. However, not every child achieves and maintains the recommended chest compression depth of 5-6cm.Purpose: To investigate the variability in compression depth for three age groups (grade 1: 12-14; grade 2: 14-16; grade 3: 16-18 years) as a function of physical characteristics and to define minimal compression excellence levels for training.Methods: Compression depth of 265 subjects (111 girls, 154 boys) aged 12-18 years from one secondary school was individually assessed and reported in percentiles per age group. Pearson correlations between physical characteristics and CPR variables were calculated. Excellence level was defined as the percentage compressions with depth 5-6cm.Results: In grade 1 (12-14 years), achieved excellence levels were 1% for girls and 23% for boys at the 75th percentile. In grade 2 (14-16 years), it increased to 24% for girls and 80% for boys. In grade 3 (16-18 years) finally, it was 59% for girls and 87% for boys. Significant positive correlations were found between CPR and physical variables (p<0.05), especially weight >50kg (p<0.01).Conclusion: A minimal excellence level of 25% is achievable by boys 12-14year and girls 14-16year and can be gradually improved to 60% and 90% according to age and gender. This might necessitate more exertion and training for some younger children, especially girls, and will probably be more easily achieved for children weighing >50kg. [ABSTRACT FROM AUTHOR]

Aims: Feedback is vital for the effective delivery of skills-based education. We sought to compare the sandwich technique and learning conversation structured methods of feedback delivery in competency-based basic life support (BLS) training.Methods: Open randomised crossover study undertaken between October 2014 and March 2015 at the University of Birmingham, United Kingdom. Six-hundred and forty healthcare students undertaking a European Resuscitation Council (ERC) BLS course were enrolled, each of whom was randomised to receive teaching using either the sandwich technique or the learning conversation. Fifty-eight instructors were randomised to initially teach using either the learning conversation or sandwich technique, prior to crossing-over and teaching with the alternative technique after a pre-defined time period. Outcome measures included skill acquisition as measured by an end-of-course competency assessment, instructors' perception of teaching with each feedback technique and candidates' perception of the feedback they were provided with.Results: Scores assigned to use of the learning conversation by instructors were significantly more favourable than for the sandwich technique across all but two assessed domains relating to instructor perception of the feedback technique, including all skills-based domains. No difference was seen in either assessment pass rates (80.9% sandwich technique vs. 77.2% learning conversation; OR 1.2, 95% CI 0.85-1.84; p=0.29) or any domain relating to candidates' perception of their teaching technique.Conclusions& Relevance: This is the first direct comparison of two feedback techniques in clinical medical education using both quantitative and qualitative methodology. The learning conversation is preferred by instructors providing competency-based life support training and is perceived to favour skills acquisition. [ABSTRACT FROM AUTHOR]

Aim Assessment skills are often neglected in resuscitation training and it has been shown that the ERC BLS/AED instructor course may be insufficient to prepare candidates for an assessment role. We have introduced an Assessment Training Programme (ATP) to improve assessors’ decision making. In this article we present our ATP and an observational study of candidates’ confidence levels upon completing both an ERC BLS/AED instructor course and our ATP. Methods Forty-seven candidates undertook the ERC instructor course and 20 qualified ERC BLS/AED instructors undertook the ATP. Pre- and post-course questionnaires were completed. Confidence was assessed on ten-point Visual Analogue Scales (VAS). Results Overall confidence on the ERC BLS/AED instructor course rose from 5.9 (SD 1.8) to 8.7 (SD 1.4) ( P < 0.001). A more modest improvement was witnessed on the ATP, rising from 8.2 (SD 1.4) to 9.6 (SD 0.5) ( P < 0.001). Upon completion of their respective courses, assessors (mean 9.6, SD 0.5) were significantly more confident at assessing than instructors (mean 8.7, SD 0.5) ( P < 0.001). Confidence in assessing individual algorithm components was similar on both courses. On the post-course questionnaire those on the ATP remained significantly more confident at assessing borderline candidates compared to instructors ( P < 0.001), with no difference for clear pass ( P = 0.067) or clear fail ( P = 0.060) candidates. Conclusion The ATP raises the confidence of assessing BLS/AED candidates to a level above that of the ERC instructor course alone. We advocate that resuscitation organisations consider integrating an ATP into their existing training structure. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the long-term effectiveness of 15-min refresher basic life support (BLS) training following 45-min chest compression-only BLS training. Methods After the 45-min chest compression-only BLS training, the participants were randomly assigned to either the refresher BLS training group, which received a 15-min refresher training 6 months after the initial training (refresher training group), or to the control group, which did not receive refresher training. Participants’ resuscitation skills were evaluated by a 2-min case-based scenario test 1 year after the initial training. The primary outcome measure was the number of appropriate chest compressions during a 2-min test period. Results 140 participants were enrolled and 112 of them completed this study. The number of appropriate chest compressions performed during the 2-min test period was significantly greater in the refresher training group (68.9 ± 72.3) than in the control group (36.3 ± 50.8, p = 0.009). Time without chest compressions was significantly shorter in the refresher training group (16.1 ± 2.1 s versus 26.9 ± 3.7 s, p < 0.001). There were no significant differences in time to chest compression (29.6 ± 16.7 s versus 34.4 ± 17.8 s, p = 0.172) and AED use between the groups. Conclusions A short-time refresher BLS training program 6 months after the initial training can help trainees retain chest compression skills for up to 1 year. Repeated BLS training, even if very short, would be adopted to keep acquired CPR quality optimal (UMIN-CTR UMIN 000004101). [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Previous studies reveal pediatric resident resuscitation skills are inadequate, with little improvement during residency. The Accreditation Council for Graduate Medical Education highlights the need for documenting incremental acquisition of skills, i.e. “Milestones”. We developed a simulation-based teaching approach “Rapid Cycle Deliberate Practice” (RCDP) focused on rapid acquisition of procedural and teamwork skills (i.e. “first-five minutes” (FFM) resuscitation skills). This novel method utilizes direct feedback and prioritizes opportunities for learners to “try again” over lengthy debriefing. Participants: Pediatric residents from an academic medical center. Methods: Prospective pre-post interventional study of residents managing a simulated cardiopulmonary arrest. Main outcome measures include: (1) interval between onset of pulseless ventricular tachycardia to initiation of compressions and (2) defibrillation. Results: Seventy pediatric residents participated in the pre-intervention and fifty-one in the post-intervention period. Baseline characteristics were similar. The RCDP-FFM intervention was associated with a decrease in: no-flow fraction: [pre: 74% (5–100%) vs. post: 34% (26–53%); p <0.001)], no-blow fraction: [pre: 39% (22–64%) median (IQR) vs. post: 30% (22–41%); p =0.01], and pre-shock pause: [pre: 84s (26–162) vs. post: 8s (4–18); p <0.001]. Survival analysis revealed RCDP-FFM was associated with starting compressions within 1min of loss of pulse: [Adjusted Hazard Ratio (HR): 3.8 (95% CI: 2.0–7.2)] and defibrillating within 2min: [HR: 1.7 (95% CI: 1.03–2.65)]. Third year residents were significantly more likely than first years to defibrillate within 2min: [HR: 2.8 (95% CI: 1.5–5.1)]. Conclusions: Implementation of the RCDP-FFM was associated with improvement in performance of key measures of quality life support and progressive acquisition of resuscitation skills during pediatric residency. [Copyright &y& Elsevier]

Background: Efficiently performed basic life support (BLS) after cardiac arrest is proven to be effective. However, cardiopulmonary resuscitation (CPR) is strenuous and rescuers’ performance declines rapidly over time. Audio-visual feedback devices reporting CPR quality may prevent this decline. We aimed to investigate the effect of various CPR feedback devices on CPR quality. Methods: In this open, prospective, randomised, controlled trial we compared three CPR feedback devices (PocketCPR®, CPRmeter®, iPhone app PocketCPR®) with standard BLS without feedback in a simulated scenario. 240 trained medical students performed single rescuer BLS on a manikin for 8min. Effective compression (compressions with correct depth, pressure point and sufficient decompression) as well as compression rate, flow time fraction and ventilation parameters were compared between the four groups. Results: Study participants using the PocketCPR® performed 17±19% effective compressions compared to 32±28% with CPRmeter®, 25±27% with the iPhone app PocketCPR®, and 35±30% applying standard BLS (PocketCPR® vs. CPRmeter® p =0.007, PocketCPR® vs. standard BLS p =0.001, others: ns). PocketCPR® and CPRmeter® prevented a decline in effective compression over time, but overall performance in the PocketCPR® group was considerably inferior to standard BLS. Compression depth and rate were within the range recommended in the guidelines in all groups. Conclusion: While we found differences between the investigated CPR feedback devices, overall BLS quality was suboptimal in all groups. Surprisingly, effective compression was not improved by any CPR feedback device compared to standard BLS. All feedback devices caused substantial delay in starting CPR, which may worsen outcome. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Existing ERC BLS/AED accreditation procedures allow BLS instructors to assess the capability of BLS/AED providers, without undergoing additional training as an assessor. The reliability of instructor-based assessment has been questioned. This study sought to determine the efficacy of a simple training programme for BLS/AED instructors aimed at standardising assessment decisions. Methods: An Assessment Training Programme (ATP) which provides additional, assessment-focused tuition for BLS instructors was introduced. Eighteen ERC accredited instructors participated in the study. Nine received standard ERC training (instructors); nine received additional training through the ATP (assessors). The assessment of 73 students’ BLS/AED capabilities was carried out by an assessor, ERC instructor and ERC instructor trainer concurrently. Participants independently completed an ERC assessment form. Decisions for instructors and assessors were compared to the instructor trainers’ decisions; those not agreeing were deemed to be incorrect. Results: Instructors (49.3%) had lower raw pass rates than assessors (67.1%) and instructor trainers (64.4%). There was a significant difference in overall decisions between instructors and instructor trainers (p =0.035), and instructors and assessors (p =0.015). There was no difference between assessors and instructor trainers (p =0.824). Instructors were more prone to incorrectly failing candidates than assessors (sensitivities of 80.5% and 63.8% respectively, p =0.077). AED-capability decisions were significantly different from instructor trainers in both the instructor (p =0.007) and assessor groups (p =0.031). Conclusion: BLS instructors incorrectly fail candidates for reasons that should not normally constitute a true assessment failure. The ATP is an effective intervention to reduce false-failure rates and improve compliance with an experienced instructor trainer''s decision. Consideration should be made to integrate such programmes into current BLS instructor accreditation procedures. [Copyright &y& Elsevier]

Abstract: Background: It is unclear whether the basic life support (BLS) and advanced life support (ALS) pre-hospital termination of resuscitation (TOR) rules developed in North America can be applied successfully to patients with out-of-hospital cardiac arrest (OHCA) in other countries. Objectives: To assess the performance of the BLS and ALS TOR in Japan. Methods: Retrospective nationwide, population-based, observational cohort study of consecutive OHCA patients with emergency responder resuscitation attempts from 1 January 2005 to 31 December 2009 in Japan. The BLS TOR rule has 3 criteria whereas the ALS TOR rule includes 2 additional criteria. We extracted OHCA patients meeting all criteria for each TOR rule, and calculated the specificity and positive predictive value (PPV) of each TOR rule for identifying OHCA patients who did not have neurologically favorable one-month survival. Results: During the study-period, 151,152 cases were available to evaluate the BLS TOR rule, and 137,986 cases to evaluate the ALS TOR rule. Of 113,140 patients that satisfied all three criteria for the BLS TOR rule, 193 (0.2%) had a neurologically favorable one-month survival. The specificity of BLS TOR rule was 0.968 (95% CI: 0.963–0.972), and the PPV was 0.998 (95% CI: 0.998–0.999) for predicting lack of neurologically favorable one-month survival. Of 41,030 patients that satisfied all five criteria for the ALS TOR rule, just 37 (0.1%) had a neurologically favorable one-month survival. The specificity of ALS TOR rule was 0.981 (95% CI: 0.973–0.986), and the PPV was 0.999 (95% CI: 0.998–0.999) for predicting lack of neurologically favorable one-month survival. Conclusions: The prehospital BLS and ALS TOR rules performed well in Japan with high specificity and PPV for predicting lack of neurologically favorable one-month survival in Japan. However, the specificity and PPV were not 1000 and we have to develop more specific TOR rules. [Copyright &y& Elsevier]

Abstract: Aim: To compare the time-dependent changes in the quality of chest compressions in 30:2 cardiopulmonary resuscitation (CPR) and hands-only cardiopulmonary resuscitation (HO-CPR) and to evaluate how individual rescuer factors affect the quality of chest compressions over time for both CPR techniques. Methods: Total 1028 adult hospital and university workers participated in CPR training programs including sessions of 30:2 CPR and HO-CPR. Tests of both CPR methods were performed in a random order using a manikin with Skill-Reporter™. Data were collected from 863 subjects. The time-dependent changes in chest compressions quality and the effects of individual rescuer factors (age, gender, body mass index (BMI), prior CPR training and experience) were analysed using the general linear model for a repeated-measures procedure. Results: In HO-CPR, the mean proportion of correct compressions depth (MPCD) decreased significantly throughout the time sectors following 20–40s (74.4–50.4% in 100–120s) compared to 30:2 CPR (83.4–76.3% in 100–120s) (p <0.0001). A significant decline of MPCD (MPCD<70%) was initially observed at 40–60s in HO-CPR, however, this pattern was not observed in 30:2 CPR. Individual rescuer factors minimally affected the time-dependent change in MPCD during 30:2 CPR. For HO-CPR, all rescuer factors except for male or obese/overweight (BMI≥25) were associated with a significant declines of MPCD, and these decline were usually observed from 40 to 60s. Conclusion: Switching rescuers at an interval of 2-min is reasonable for 30:2 CPR. However, for HO-CPR switching rescuers every 1-min may be preferable except when rescuers are male or obese/overweight (BMI≥25). [Copyright &y& Elsevier]

Abstract: Background: Cardiopulmonary resuscitation (CPR) mastery continues to challenge medical professionals. The purpose of this study was to determine if an emotional stimulus in combination with peer or expert feedback during pre-course assessment effects future performance in a single rescuer simulated cardiac arrest. Methods: First-year medical students (n =218) without previous medical knowledge were randomly assigned to one of the study groups and asked to take part in a pre-course assessment: Group 1: after applying an emotionally activating stimulus an expert (instructor) gave feedback on CPR performance (Ex). Group 2: after applying the same stimulus feedback was provided by a peer from the same group (Pe); Group 3: standard without feedback (S). Following pre-course assessment, all subjects received a standardized BLS-course, were tested after 1week and 6months later using single-rescuer-scenario, and were surveyed using standardized questionnaires (6-point-likert-scales: 1=completely agree, 6=completely disagree). Results: Participants exposed to stimulus demonstrated superior performance concerning compression depth after 6months independent of feedback-method (Ex: 65.85% [p =0.0003]; Pe: 57.50% [p =0.0076] vs. 21.43%). The expert- more than the peer-group was emotionally more activated in initial testing, Ex: 3.26±1.35 [p ≤0.0001]; Pe: 3.73±1.53 [p =0.0319]; S: 4.25±1.37) and more inspired to think about CPR (Ex: 2.03±1.37 [p =0.0119]; Pe: 2.07±1.14 [p =0.0204]; S: 2.60±1.55). After 6months this activation effect was still detectable in the expert-group (p =0.0114). Conclusions: The emotional stimulus approach to BLS-training seems to impact the ability to provide adequate compression depth up to 6months after training. Furthermore, pre-course assessment helped to keep the participants involved beyond initial training. [Copyright &y& Elsevier]

Abstract: Aim of the study: The aim of this study was to study exercise-related cardiac arrests on the tennis court and investigate the impact of early initiation of cardiopulmonary resuscitation on survival rate and outcome. Methods: This study was based on the cardiac arrest registry of the Department of Emergency Medicine at the General Hospital Vienna in Austria. Between February 1993 and April 2010 non-professional athletes were identified, who experienced exercise-related cardiac arrest on the tennis court. The analysis was accomplished using descriptive statistics. Results are presented as mean±standard-deviation or median and interquartile range (IQR). Results: The subjects (n =27) were predominantly male (96%) with a median age of 58 years; 52% of all patients had underlying cardiovascular risk factors. All cardiac arrests were witnessed. Bystander CPR was documented in 17 cases (63%). Median time from collapse to initiation of CPR was 1(IQR 0–2) minute. Ventricular fibrillation was the initial rhythm in 25 patients (93%) and in 3 an automated external defibrillator was used by bystanders. Twenty-four patients (89%) had return of spontaneous circulation before admission to the hospital and four (15%) followed verbal commands thereafter. The survival rate at 6 months was 82% with 20 patients (74%) having favourable neurologic outcome. Conclusions: Cardiac arrest on the tennis court is a predominantly witnessed event with a respectively high rate of bystander CPR, which reflects in a high successful survival rate. [Copyright &y& Elsevier]

Abstract: Background: Early bystander cardiopulmonary resuscitation (CPR) is essential for survival from out-of-hospital cardiac arrest (OHCA). Young people are potentially important bystander CPR providers, as basic life support (BLS) training can be distributed widely as part of the school curriculum. Methods: Questionnaires were distributed to nine secondary schools in North Norway, and 376 respondents (age 16–19 years) were included. The completed questionnaires were statistically analysed to assess CPR knowledge and attitude to performing bystander CPR. Results: Theoretical knowledge of handling an apparently unresponsive adult person was high, and 90% knew the national medical emergency telephone number (113). The majority (83%) was willing to perform bystander CPR in a given situation with cardiac arrest. However, when presented with realistic hypothetical cardiac arrest scenarios, the option to provide full BLS was less frequently chosen, to e.g. a family member (74%), a child (67%) or an intravenous drug user (18%). Students with BLS training in school and self-reported confidence in their own BLS skills reported stronger willingness to perform BLS. 8% had personally witnessed a cardiac arrest, and among these 16% had performed full BLS. Most students (86%) supported mandatory BLS training in school, and three out of four wanted to receive additional training. Conclusion: Young Norwegians are motivated to perform bystander CPR, but barriers are still seen when more detailed cardiac arrest scenarios are presented. By providing students with good quality BLS training in school, the upcoming generation in Norway may strengthen the first part of the chain of survival in OHCA. [Copyright &y& Elsevier]

Abstract: Background: This study aimed to evaluate the association of cardiopulmonary resuscitation (CPR) training with bystander resuscitation performance and patient outcomes after out-of-hospital cardiac arrest (OHCA). Methods: This was a prospective, population-based cohort study of all persons aged 18years or older with OHCA of presumed intrinsic origin and their rescuers from January through December 2008 in Takatsuki, Osaka prefecture, Japan. Data on resuscitation of OHCA patients were obtained by emergency medical service (EMS) personnel in charge based on the Utstein style. Rescuers’ characteristics including experience of CPR training were obtained by EMS personnel interview on the scene. The primary outcome was the attempt of bystander CPR. Results: Data were collected for 120 cases out of 170 OHCAs of intrinsic origin. Among the available cases, 60 (50.0%) had previous CPR training (trained rescuer group). The proportion of bystander CPR was significantly higher in the trained rescuer group than in the untrained rescuer group (75.0% and 43.3%; p =0.001). Bystanders who had previous experience of CPR training were 3.40 times (95% confidence interval 1.31–8.85) more likely to perform CPR compared with those without previous CPR training. The number of patients with neurologically favorable one-month survival was too small to evaluate statistical difference between the groups (2 [3.3%] in the trained rescuer group versus 1 [1.7%] in the untrained rescuer group; p =0.500). Conclusions: People who had experienced CPR training had a greater tendency to perform bystander CPR than people without experience of CPR training. Further studies are needed to prove the effectiveness of CPR training on survival. [Copyright &y& Elsevier]

Abstract: Aim: Effective assessment of motor skills in large-size classes is a challenge in medical education. This case-study investigates whether a game can be considered a valid tool for the summative assessment of first aid and basic life support skills. Methods: Using a traditional exam as bench-mark, a board game format was experimentally trialed to assess students’ competency after taking a first aid course. Fifty-five students were randomly assigned to two groups. Two assessments, a game-based assessment and a traditional test, consisting of a paper-and-pencil test in combination with a skill assessment, were applied to both groups in opposite order. In both formats students acted as judges of other students’ efforts. In the game, the student''s outcome was equal to the number of cards collected by answering questions correctly as deemed by peers. Similarities between both assessment types included individual testing, type of assessor (peers), content, type of questions and demonstrations, and the use of checklists for skill assessment. The assessment methods differed in format (written or oral test, both in combination with skill assessment) and feedback availability. Results: Both groups performed equally in the game-based assessment as well as in the traditional test, in spite of the opposite order of the assessments. No significant difference was found between the mean scores on the game-based assessment and the traditional test. Conclusions: These data suggest that use of a game format for assessment purposes may provide an effective means of assessing students’ competence at the end of a practical course. [Copyright &y& Elsevier]

Abstract: Background: Little is known about the effect of the type of bystander-initiated cardiopulmonary resuscitation (CPR) for prolonged out-of-hospital cardiac arrest (OHCA). Objectives: To evaluate the time-dependent effectiveness of chest compression-only and conventional CPR with rescue breathing for witnessed adult OHCA of cardiac origin. Methods: A nationwide, prospective, population-based, observational study of the whole population of Japan included consecutive OHCA patients with emergency responder resuscitation attempts from 1 January 2005 to 31 December 2007. Multiple logistic regression analysis was performed to assess the contribution of the bystander-initiated CPR technique to favourable neurological outcomes. Results: Among 55014 bystander-witnessed OHCA of cardiac origin, 12165 (22.1%) received chest compression-only CPR and 10851 (19.7%) received conventional CPR. For short-duration OHCA (0–15min after collapse), compression-only CPR had a higher rate of survival with favourable neurological outcome than no CPR (6.4% vs. 3.8%; adjusted odds ratio (OR), 1.55; 95% confidence interval (CI), 1.38–1.74), and conventional CPR showed similar effectiveness (7.1% vs. 3.8%; adjusted OR, 1.78; 95% CI, 1.58–2.01). For the long-duration arrests (>15min), conventional CPR showed a significantly higher rate of survival with favourable neurological outcome than both no CPR (2.0% vs. 0.7%; adjusted OR, 1.93; 95% CI, 1.27–2.93) and compression-only CPR (2.0% vs. 1.3%; adjusted OR, 1.56; 95% CI, 1.02–2.44). Conclusions: For prolonged OHCA of cardiac origin, conventional CPR with rescue breathing provided incremental benefit compared with either no CPR or compression-only CPR, but the absolute survival was low regardless of type of CPR. [ABSTRACT FROM AUTHOR]

Abstract: Background: Video-based self-instruction (VSI) with a 24-min DVD and a personal resuscitation manikin solves some of the barriers associated with traditional basic life support (BLS) courses. No accurate assessment of the actual improvement in skills after attending a VSI course has been determined, and in this study we assess the skill improvement in laypersons undergoing VSI. Methods: The BLS skills of 68 untrained laypersons (high school students, their teachers and persons excluded from mainstream society) were assessed using the Laerdal ResusciAnne and PC Skill Reporting System 2.0 in a 3min test. A total score (12–48 points) was calculated and 12 different variables were recorded. The participants attended a 24-min VSI course (MiniAnne, Laerdal) and took home the DVD and manikin for optional subsequent self-training. We repeated the test 3½–4 months later. Results: There was a significant increase in the total score (p <0.0001) from 26.5 to 34 points. The participants performed significantly better in checking responsiveness, opening the airway, checking for respiration and using the correct compression/ventilation ratio (all p-values<0.001). The compression depth improved from 38mm to 49.5mm and the total number of compressions increased from 67 to 141. The ventilation volume and the total number of ventilations increased, and total “hands-off” time decreased from 120.5s to 85s. Conclusions: Untrained laypersons attending a 24min DVD-based BLS course have a significantly improved BLS performance after 3½–4 months compared to pre-test skill performance. Especially the total number of compressions improved and the hands-off time decreased. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: This study aimed to compare the time-dependent deterioration of chest compressions between chest compression-only cardiopulmonary resuscitation (CPR) and conventional CPR. Methods: This study involved 106 and 107 participants randomly assigned to chest compression-only CPR training and conventional CPR training, respectively. Immediately after training, participants were asked to perform CPR for 2min and the quality of their CPR skills were evaluated. The number of chest compressions in total and those with appropriate depth were counted every 20-s CPR period from the start of CPR. The primary outcome was the CPR quality index calculated as the proportion of chest compressions with appropriate depth among total chest compressions. Results: The total number of chest compressions remained stable over time both in the chest compression-only and the conventional CPR groups. The CPR quality index, however, decreased from 86.6±25.0 to 58.2±36.9 in the chest compression-only CPR group from 0–20s through 61–80s. The reduction was greater than in the conventional CPR group (85.9±25.5 to 74.3±34.0). The difference in the CPR quality index reached statistical significance (p =0.003) at 61–80s period. Conclusions: Chest compressions with appropriate depth decreased more rapidly during chest compression-only CPR than conventional CPR. We recommend that CPR providers change their roles every 1min to maintain the quality of chest compressions during chest compression-only CPR. (UMIN-CTR C0000000321) [ABSTRACT FROM AUTHOR]

Abstract: Background: Self-directed BLS-training, using a personal training manikin with video has been shown to be as effective as instructor-led training. This has not previously been investigated for AED-training. Materials and methods: This prospective, randomized study with a non-inferiority design compared traditional instructor-led training with three DVD-based AED-training methods (2.5min DVD without practice; 4.5min DVD with manikin practice; 9min DVD with manikin practice and scenario training). After DVD BLS-training, 396 participants were assigned to one of the four AED-training methods by randomization stratified for age. Participants were tested immediately after the training (post-test) and 2 months later (retention-test) using modified Cardiff criteria. The primary endpoint was the percentage of providers scoring 70% or higher on testing. The secondary endpoints were the mean scores and differences per item per age group. Results: Comparison non-inferiority could not be accepted for the post-test or retention-test. Relative risk (RR) and 95% confidence interval (CI) of passing for DVD without practice, with manikin practice and with manikin practice and scenario training compared to instructor-led training were 0.36 (0.25–0.53), 0.35 (0.24–0.51), 0.55 (0.38–0.79), respectively for the post-test, and 0.82 (0.68–0.97), 0.82 (0.68–0.97), and 0.84 (0.70–1.00), respectively for the retention-test. The performance of participants in all DVD-based training groups was significantly higher on the retention-test than on the post-test. Those receiving scenario training scored higher on the post-test compared to the other DVD-training groups (p <0.001). Conclusions: DVD-based AED-training without scenario is not recommended. Scenario training is a useful addition, but instructor-facilitated training remains the best method. [ABSTRACT FROM AUTHOR]

Abstract: Background: The increasing survival rates after out-of-hospital cardiac arrests (OHCA) are due mainly to improvements in the first 3 steps of the chain of survival. The aim of this study was to describe the temporal trends of OHCA incidence and outcomes with shock-resistant ventricular fibrillation (VF) requiring advanced life support procedures. Methods: All our subjects were persons aged 18 years or more who had suffered OHCA of presumed cardiac etiology, were witnessed by bystanders, treated by emergency medical service (EMS), and had VF as initial rhythm. Our study was conducted in Osaka Prefecture, Japan from May 1, 1998 through December 31, 2006. Data were collected by EMS personnel using an Utstein-style database. We evaluated the temporal trends of incidence and outcomes of shock-resistant VF. Results: During the study period, there were 8782 witnessed OHCA cases of presumed cardiac etiology. Among them, 1733 had VF as an initial rhythm, 392 of whom were shock-resistant. While the age-adjusted annual incidence of witnessed VF increased from 2.0 to 3.3 per 100,000 inhabitants, that of shock-resistant VF underwent little change during the study period. The proportion of shock-resistant VF among witnessed VF decreased from 37.0% to 19.0%. Neurologically intact 1-month survival rates after shock-resistant VF remained low at 5.6% even in 2006. Conclusion: The actual incidence of shock-resistant VF has remained unchanged, and their outcomes continue to be dismal. Further efforts are required to reduce the mortality rates of such shock-resistant VF to achieve improved survival after OHCA. [Copyright &y& Elsevier]

Abstract: Introduction: Quality of external chest compression (ECC) is a key component of Basic Life Support. Different approaches to improve rescuers’ performance have been evaluated, but few attempts have been made to invent simple devices to improve performance. This study evaluates a new visual feedback system for ECC for healthcare professionals. Methods: Ninety-three healthcare professionals volunteered (14 emergency medical technicians, 45 paramedics, 34 physicians; age 32±7.2 (range 21–61); 72% male) in this randomized cross-over study. All subjects were tested on a manikin (Skillreporter ResusciAnne®, Laerdal, Stavanger, Norway) in identical mock cardiac arrest scenario and asked to perform 2min of continuous ECC (secured airway): Group A (n =46): ECC with device first, followed by ECC without device a minimum of 45min later; group B (n =47): vice versa. Primary endpoints: mean compression rate 90–120min−1; mean compression depth 38–51mm. Data were analyzed using repeated measure logistic regression model for binary categorized endpoints and repeated measure ANOVA test for continuous endpoints. Results: Correct compression depth was achieved by 45.2% of subjects (95%-CI: 30.5–64.9mm) without vs. 73.1% (95%-CI: 40.3–57.4mm) with device (p <0.001); correct compression rate was achieved by 62.4% (95%-CI: 78–147.8min−1) without vs. 94.6% (95%-CI: 87.3–126.6min−1) with device (p <0.001). Overall, 85% of the subjects thought the feedback system was helpful and 80.6% would use it if available. Conclusions: The new visual feedback device significantly improved ECC performance (compression rate and depth) by healthcare professionals in simulated cardiac arrest. Most participants found the device easy to use. [Copyright &y& Elsevier]

Abstract: National resuscitation guidelines were published in Finland in 2002 and updated in 2006. The purpose of this study was to analyse the effect of cardiopulmonary resuscitation (CPR) education on attitudes towards defibrillation during arrests (CPR-D) and the guidelines. Methods: In 2003 (before CPR-D education) and in 2007 (after the education), 48-item questionnaires (using a 7-point Likert scale: 1=totally disagree, 7=totally agree) were sent to nurses in a secondary hospital. Factor loadings were applied using maximum likelihood factor analyses with a varimax rotation. Five scales were built from the items of the questionnaire: attitudes towards CPR-D, positive attitudes, negative attitudes towards guidelines, implementation and nurses’ role. Results: A total of 297 and 199 responded in 2003 and 2007, respectively. Education increased positive attitudes towards CPR-D (scale mean: 4.40 vs. 3.61, 95% confidence interval (CI): 3.9–4.2, P <0.001). Nevertheless, 27% of nurses hesitated to perform defibrillation because of fear of injuring patient and 64% because of anxiety. After education, negative attitudes towards guidelines increased (scale mean 2.94 vs. 3.92, 95% CI: 3.2–3.6, P <0.001) and nurses were more unsure about their role than before education (scale mean: 4.84 vs. 3.42, 95% CI: 4.1–4.4, P <0.001). Conclusions: Intensive education increased self-confidence regarding CPR-D skills but did not reduce anxiety. CPR-D education should include a focus on reducing anxiety, and negative attitudes within organisations need to be explored. [Copyright &y& Elsevier]

Abstract: Background: Research emphasises the need for instructional methods and tools which can improve Basic Life Support (BLS) performance or reduce instructional time. Aim: To investigate the effect of peer evaluation to improve reciprocal learning with task cards as instructional tools for acquiring BLS. Methods: A total of 78 kinesiology students from a Belgian university were paired and randomised across two groups to learn BLS in 20min with task cards. In the control group, students worked together in a defined doer–helper relationship and switched roles every 5min. In the peer evaluation group, students followed the same co-operation procedure as in the control group. In addition, 1min before every switching of roles, the helper evaluated the doer''s performance. All BLS skills were individually assessed on a Laerdal AED Resusci Anne mannequin (Laerdal Medical, Vilvoorde, Belgium) using the Laerdal PC-Skill reporting system. A total BLS score was calculated and performance was measured before training (baseline), immediately after training (intervention) and 2 weeks later (retention). Results: Significantly more students from the evaluation group remembered and consequently performed all BLS skills at intervention (P =0.03). No significant differences were found between groups for main cardiopulmonary resuscitation (CPR) variables and total BLS scores at baseline, intervention and retention. Both groups achieved more than 70% of the maximum BLS score at intervention and retention. Conclusions: This study demonstrated that 20min reciprocal-learning setting with task cards is an effective method to learn BLS. The implementation of peer evaluation in this setting has an immediate, however small, positive impact on BLS skill learning. [Copyright &y& Elsevier]

Abstract: Objective: To explore in detail the expected magnitude of systemic perfusion pressure during standard CPR as a function of compression frequency for different sized people from neonate to adult. Method: A 7-compartment mathematical model of the human cardiopulmonary system – upgraded to include inertance of blood columns in the aorta and vena cavae – was exercised with parameters scaled to reflect changes in body weight from 1 to 70kg. Results: Maximal systemic perfusion pressure occurs at chest compression rates near 60, 120, 180, and 250/min for subjects weighing 70, 10, 3, and 1kg, respectively. Such maxima are predicted by analytical models describing the dependence of stroke volume on pump-filling time in the presence of blood inertia. This mathematical analysis reproduces earlier experimental results of Fitzgerald et al. in 10kg dogs. Conclusions: Fundamental geometry and physics suggest that the most effective chest compression frequency in CPR depends upon body size and weight. In neonates there is room for improvement at the top of the compression frequency scale at rates >120/min. In adults there may be benefit from lower compression frequencies near 60/min. [Copyright &y& Elsevier]

Abstract: Objectives: To evaluate the effectiveness of 1-h practical chest compression-only cardiopulmonary resuscitation (CPR) training with or without a preparatory self-learning video. Methods: Participants were randomly assigned to either a control group or a video group who received a self-learning video before attending the 1-h chest compression-only CPR training program. The primary outcome measure was the total number of chest compressions during a 2-min test period. Results: 214 participants were enrolled, 183 of whom completed this study. In a simulation test just before practical training began, 88 (92.6%) of the video group attempted chest compressions, while only 58 (64.4%) of the control group (p <0.001) did so. The total number of chest compressions was significantly greater in the video group than in the control group (100.5±61.5 versus 74.4±55.5, p =0.012). The proportion of those who attempted to use an automated external defibrillator (AED) was significantly greater in the video group (74.7% versus 28.7%, p <0.001). After the 1-h practical training, the number of total chest compressions markedly increased regardless of the type of CPR training program and inter-group differences had almost disappeared (161.0±31.8 in the video group and 159.0±35.7 in the control group, p =0.628). Conclusions: 1-h chest compression-only CPR training makes it possible for the general public to perform satisfactory chest compressions. Although a self-learning video encouraged people to perform CPR, their performance levels were not sufficient, confirming that practical training as well is essential. (UMIN000001046). [Copyright &y& Elsevier]

Abstract: Background: During cardiac arrest the paramount goal of basic life support (BLS) is the oxygenation of vital organs. Current recommendations are to combine chest compressions with ventilation in a fixed ratio of 30:2; however the optimum compression/ventilation ratio is still debatable. In our study we compared four different compression/ventilation ratios and documented their effects on the return of spontaneous circulation (ROSC), gas exchange, cerebral tissue oxygenation and haemodynamics in a pig model. Methods: Study was performed on 32 pigs under general anaesthesia with endotracheal intubation. Arterial and central venous lines were inserted. For continuous cerebral tissue oxygenation a Licox® PtiO2 probe was implanted. After 3min of cardiac arrest (ventricular fibrillation) animals were randomized to a compression/ventilation-ratio 30:2, 100:5, 100:2 or compressions-only. Subsequently 10min BLS, Advanced Life Support (ALS) was performed (100%O2, 3 defibrillations, 1mg adrenaline i.v.). Data were analyzed with 2-factorial ANOVA. Results: ROSC was achieved in 4/8 (30:2), 5/8 (100:5), 2/8 (100:2) and 0/8 (compr-only) pigs. During BLS, PaCO2 increased to 55mmHg (30:2), 68mmHg (100:5; p =0.0001), 66mmHg (100:2; p =0.002) and 72mmHg (compr-only; p <0.0001). PaO2 decreased to 58mmg (30:2), 40mmHg (100:5; p =0.15), 43mmHg (100:2; p =0.04) and 26mmHg (compr-only; p <0.0001). PtiO2 baseline values were 12.7, 12.0, 11.1 and 10.0mmHg and decreased to 8.1mmHg (30:2), 4.1mmHg (100:5; p =0.08), 4.3mmHg (100:2; p =0.04), and 4.5mmHg (compr-only; p =0.69). Conclusions: During BLS, a compression/ventilation-ratio of 100:5 seems to be equivalent to 30:2, while ratios of 100:2 or compressions-only detoriate peripheral arterial oxygenation and reduce the chance for ROSC. [Copyright &y& Elsevier]

Abstract: Studies have shown that the quality of chest compressions for cardiac arrest decreases markedly after only a brief time. This is thought to be an important contributor to an adverse outcome of resuscitation, which has led to recommendations to alternate chest compression providers. This study compared alternating rescuers every 1min versus every 2min in a manikin simulation. Forty pairs of rescuers were randomly assigned to either scenario. The main outcome measure was the number of effective compressions. The results were analysed using one-way analysis of variance. Over the full 8min, no significant difference was found in the number of effective chest compressions (p =0.707). Furthermore, no significant difference was found when comparing each 2min block. An explanation for this may be that the compressions lost due to fatigue in the 2min scenario are approximately offset by compressions lost due to the practicalities of changing over. Power calculations with these results show that an unfeasibly large number of scenarios would be needed to definitively demonstrate the superiority of one of the scenarios. It seems reasonable to alternate chest compression providers every 2min, to prevent the loss of effective compressions due to fatigue and to minimise interruptions of chest compressions. The ideal time to do this would be during the rhythm and pulse check as dictated by current guidelines. [Copyright &y& Elsevier]

Abstract: Aims: Basic Life Support Guidelines 2005 emphasise the importance of reducing interruptions in chest compressions (no-flow duration) yet at the same time stopped recommending Dual Operator CPR. Dual Operator CPR (where one rescuer does ventilations and one chest compressions) could potentially minimize no-flow duration compared to Single Operator CPR. This study aims to determine if Dual Operator CPR reduces no-flow duration compared to Single Operator CPR. Methodology: This was a prospective randomised controlled crossover trial. Medical students were randomised into ‘Dual Operator’ or ‘Single Operator’ CPR groups. Both groups performed 4min of CPR according to their group allocation on a resuscitation manikin before crossing over to perform the other technique one week later. Results: Fifty participants were recruited. Dual Operator CPR achieved slightly lower no-flow durations than the Single Operator CPR (28.5% (S.D.=3.7) versus 31.6% (S.D.=3.6), P ≤0.001). Dual Operator CPR was associated with slightly more rescue breaths per minute (4.9 (S.D.=0.5) versus 4.5 (S.D.=0.5), P =0.009. There was no difference in compression depth, compression rate, duty cycle, rescue breath flow rate or rescue breath volume. Conclusions: Dual Operator CPR with a compression to ventilation rate of 30:2 provides marginal improvement in no-flow duration but CPR quality is otherwise equivalent to Single Operator CPR. There seems little advantage to adding teaching on Dual Operator CPR to lay/trained first responder CPR programs. [Copyright &y& Elsevier]

Abstract: Introduction: The use of a personal resuscitation manikin with video instruction is reportedly as effective as traditional instructor-led courses in teaching lay people basic life support (BLS). We applied this method to an entire hospital staff to determine its effect on their practical and self-judged BLS skills. Methods: All 5382 employees at Stavanger University Hospital were asked to learn or refresh their BLS skills with the personal resuscitation manikin and video instruction. Prior to and nine months after training, all employees were asked to rate their BLS skills on a scale from one to five. Additionally, randomly chosen study subjects were tested for BLS skills pre-training and six months post-training during 2min of resuscitation on a manikin. Results: In total, 5118 employees took part in the BLS training program. The number of correct chest compressions increased significantly from 60 (5–102) to 119 (75–150) in the pre- vs. post-training periods, respectively, P <0.01, but the number of correct MTM ventilations did not change. Self-reported BLS skills increased from 3.1 (±1.0) pre-training to 3.8 (±0.8) post-training, P =0.031. Conclusion: After distributing a personal resuscitation manikin with video instruction to an entire hospital staff, the median number of correctly performed chest compressions doubled and self-confidence in BLS skills improved significantly. This is a simple and less time-consuming method than instructor-led courses in preparing hospital employees in the basic handling of cardiac arrest. [Copyright &y& Elsevier]

Abstract: Purpose: To evaluate, in a hospital setting, the influence of different, common mattresses, with and without a backboard, on chest movement during CPR. Design and setting: Sixty CPR sessions (140s each, 30:2, C:R ratio 1:1) were performed using a manikin on standard hospital mattresses, with or without a backboard in combination with variable weights. Sternum-to-spine compression distance was controlled (range 30–60mm) allowing evaluation of the underlying compliant surface on total hand travel. Results: Movement of the caregiver''s hands was significantly larger (up to 111mm at 50mm compression depth, p <0.0001) when sternum-to-spine compressions were performed without a backboard than with one. The extent of this variable extra travel effect depended on the type of mattress as well as the force of compression. Foam mattresses and air chamber systems act as springs and follow hand movement, while ‘slow foam’ mattresses incorporate time delays, making depth and force sensing harder. A backboard decreases the extra hand movement due to mattress effects by more than 50%, strongly reducing caregiver work. Conclusions: Total vertical hand movement is significantly, and clinically relevantly much, larger than sternum-to-spine compression depth when CPR is performed on a mattress. Additional movement depends on the type of mattress and can be strongly reduced, but not eliminated, when a backboard is applied. The additional motion and increased work load adds extra complexity to in-hospital CPR. We propose that this should be taken into account during training by in-hospital caregivers. [Copyright &y& Elsevier]

Abstract: Aim: Stomach inflation during cardiopulmonary resuscitation (CPR) is frequent, but the effect on haemodynamic and pulmonary function is unclear. The purpose of this study was to evaluate the effect of clinically realistic stomach inflation on haemodynamic and pulmonary function during CPR in a porcine model. Methods: After baseline measurements ventricular fibrillation was induced in 21 pigs, and the stomach was inflated with 0L (n =7), 5L (n =7) or 10L air (n =7) before initiating CPR. Results: During CPR, 0, 5, and 10L stomach inflation resulted in higher mean pulmonary artery pressure [median (min–max)] [35 (28–40), 47 (25–50), and 51 (49–75) mmHg; P <0.05], but comparable coronary perfusion pressure [10 (2–20), 8 (4–35) and 5 (2–13) mmHg; P =0.54]. Increasing (0, 5, and 10L) stomach inflation decreased static pulmonary compliance [52 (38–98), 19 (8–32), and 12 (7–15) mL/cmH2O; P <0.05], and increased peak airway pressure [33 (27–36), 53 (45–104), and 103 (96–110) cmH2O; P <0.05). Arterial oxygen partial pressure was higher with 0L when compared with 5 and 10L stomach inflation [378 (88–440), 58 (47–113), and 54 (43–126) mmHg; P <0.05). Arterial carbon dioxide partial pressure was lower with 0L when compared with 5 and 10L stomach inflation [30 (24–36), 41(34–51), and 56 (45–68) mmHg; P <0.05]. Return of spontaneous circulation was comparable between groups (5/7 in 0L, 4/7 in 5L, and 3/7 in 10L stomach inflation; P =0.56). Conclusions: Increasing levels of stomach inflation had adverse effects on haemodynamic and pulmonary function, indicating an acute abdominal compartment syndrome in this CPR model. [Copyright &y& Elsevier]

Abstract: Aim: In order to elucidate the factors for willingness to perform CPR, we evaluated the responses of college students to questionnaires before and after basic life support (BLS) training. Methods: Before and after participating in a small group BLS course, 259 students completed questionnaires. A logistic regression model was used to elucidate independent factors for their willingness to attempt resuscitation. Results: Factors associated with willingness to perform BLS for strangers were “anxiety for a bad outcome” (odds ratio (OR) 0.08) and “having knowledge of automated external defibrillator (AED)” (OR 4.5) before training. The proportion of students showing willingness to perform BLS increased from 13% to 77% after the training even when the collapsed person is a stranger. After training, “anxiety for being sued because of a bad outcome” (OR 0.3), and “anxiety for infection” (OR 3.8) were significant factors. Those who preferred to perform BLS without ventilation increased from 40% to 79% (p <0.0001). Conclusion: The proportion of students showing willingness to perform BLS increased after the training. Significant association between “anxiety for infection” and willingness to perform BLS might indicate that those who wish to perform BLS developed their awareness of risk of infection more than the counterparts. For future guidelines for resuscitation and the instruction consensus, the reluctance of bystanders to perform CPR due to the hesitation about mouth-to-mouth ventilation should be reconsidered with other recent reports indicating the advantage of compression-only CPR. [Copyright &y& Elsevier]

Summary: Background: The ECG analysis algorithm of automated external defibrillators (AEDs) shows reduced sensitivity and specificity in the presence of external artifacts. Therefore, ECG analyses are preceded by voice prompts. We investigated if advanced life support (ALS) providers follow these prompts, and the consequences if they do not. Methods: In a two-tiered EMS system all 510 ECG analyses from 135 resuscitation attempts with a Laerdal® FR2 AED (applied by emergency medical technicians [EMTs] and subsequently used by ALS providers) were prospectively evaluated. The ALS data were compared with data before arrival of ALS providers (EMT data) using Mc Nemar test. Results: In the presence of ALS providers, 286 ECG rhythm analyses were performed. In the 96 analyses with shockable rhythms, artifacts were detected in 35 (36%), leading to a wrongful no shock decision in 19 (20%). Corresponding EMT data were 67 analyses with shockable rhythms, with artifacts in 18 (27%; p <0.001) but a wrongful no shock decision in only 3 (4%; p <0.001). ALS providers also failed to deliver the AED shock in 7 of the 77 analyses with an appropriate shock decision (9%). This was never found in the EMT data. In the 190 analyses of a non-shockable rhythm in the presence of ALS providers, artifacts were detected in 120 (63%) leading to one spurious shock (0.5%). Corresponding EMT data were 157 analyses, with artifacts in 87 (55%; p =0.20) but no spurious shocks. Conclusions: External artifacts were frequently found, sometimes leading to important errors. Consequently, more training is needed, especially for ALS providers. [Copyright &y& Elsevier]

Summary: Aim: To determine whether in patients with an ambulance response time of >5min who were in VF cardiac arrest, 3min of CPR before the first defibrillation was more effective than immediate defibrillation in improving survival to hospital discharge. Methods: This randomised control trial was run by the South Australian Ambulance Service between 1 July, 2005, and 31 July, 2007. Patients in VF arrest were eligible for randomisation. Exclusion criteria were: (i) <18 years of age, (ii) traumatic arrest, (iii) paramedic witnessed arrest, (iv) advanced life support performed before arrival of paramedics and (v) not for resuscitation order or similar directive. The primary outcome was survival to hospital discharge with secondary outcomes being neurological status at discharge, the rate of return of spontaneous circulation (ROSC) and the time from first defibrillation to ROSC. Results: For all response times, no differences were observed between the immediate defibrillation group and the CPR first group in survival to hospital discharge (17.1% [18/105] vs. 10.3% [10/97]; P =0.16), the rate of ROSC (53.3% [56/105] vs. 50.5% [49/97]; P =0.69) or the time from the first defibrillation to ROSC (12:37 vs. 11:19; P =0.49). There were also no differences between the immediate defibrillation group and the CPR first group, for response times of ≤ or > 5min: survival to hospital discharge (50.0% [7/14] vs. 25.0% [4/16]; P =0.16 or 12.1% [11/91] vs.7.4% [6/81]; P =0.31, respectively) and the rate of ROSC (71.4% [10/14] vs. 75.0% [12/16]; P =0.83 or 50.5% [46/91] vs. 45.7% [37/81]; P =0.54, respectively). No differences were observed in the neurological status of those surviving to hospital discharge. Conclusion: For patient in out-of-hospital VF cardiac arrest we found no evidence to support the use of 3min of CPR before the first defibrillation over the accepted practice of immediate defibrillation. [Copyright &y& Elsevier]

Summary: Objectives: To compare the quality of resuscitation between those with a simplified chest compression-only cardiopulmonary resuscitation (CPR) program and those with a conventional CPR program. Methods: The participants were randomly assigned to either the 120-min training program of chest compressions (chest compression-only CPR) or the 180-min training program of chest compressions and ventilations (conventional CPR). Main outcome measures were the net number of appropriate chest compressions during the 2-min test period and the proportion of appropriate chest compressions over the theoretically attainable number one month after the training. Results: 223 participants were enrolled and 104 in each group completed this study. The 2-min number of appropriate chest compressions was 86.1±57.2 in the chest compression-only CPR group, which was significantly greater than 57.1±30.2 in the conventional CPR group (p <0.001). The proportion of appropriate chest compressions was higher in the chest compression-only CPR group than in the conventional CPR group (47.1±31.1% versus 38.1±20.1%, p =0.022). Time without chest compressions during conventional CPR reached 85.5±17.0s out of 120s, which was significantly longer than that during chest compression-only CPR (33.9±10.0s, p <0.001). The total number of ventilations and the number of appropriate ventilations during 2min was 2.5±3.0 and 0.9±1.6, respectively. Conclusions: A simplified chest compression-only CPR program makes it possible for the general public to perform a greater number of appropriate chest compressions than the conventional CPR program (UMIN-CTR C0000000321). [Copyright &y& Elsevier]

Summary: Aim: The importance of ventilatory support during cardiac arrest and basic life support is controversial. This experimental study used dynamic computed tomography (CT) to assess the effects of chest compressions only during cardiopulmonary resuscitation (CCO-CPR) on alveolar recruitment and haemodynamic parameters in porcine model of ventricular fibrillation. Materials and methods: Twelve anaesthetized pigs (26±1kg) were randomly assigned to one of the following groups: (1) intermittent positive pressure ventilation (IPPV) both during basic life support and advanced cardiac life support, or (2) CCO during basic life support and IPPV during advanced cardiac life support. Measurements were acquired at baseline prior to cardiac arrest, during basic life support, during advanced life support, and after return of spontaneous circulation (ROSC), as follows: dynamic CT series, arterial and central venous pressures, blood gases, and regional organ blood flow. The ventilated and atelectatic lung area was quantified from dynamic CT images. Differences between groups were analyzed using the Kruskal–Wallis test, and a p <0.05 was considered statistically significant. Results: IPPV was associated with cyclic alveolar recruitment and de-recruitment. Compared with controls, the CCO-CPR group had a significantly larger mean fractional area of atelectasis (p =0.009), and significantly lower PaO2 (p =0.002) and mean arterial pressure (p =0.023). The increase in mean atelectatic lung area observed during basic life support in the CCO-CPR group remained clinically relevant throughout the subsequent advanced cardiac life support period and following ROSC, and was associated with prolonged impaired haemodynamics. No inter-group differences in myocardial and cerebral blood flow were observed. Conclusion: A lack of ventilation during basic life support is associated with excessive atelectasis, arterial hypoxaemia and compromised CPR haemodynamics. Moreover, these detrimental effects remain evident even after restoration of IPPV. [Copyright &y& Elsevier]

Summary: Aim: To examine the current status and problems of resuscitation management in Japan as demonstrated at the 2006 and 2007 Osaka Senri medical rallies. Methods: Using manikins, the quality of resuscitation was evaluated in 33 teams that participated in the medical rallies. The challenge was to deliver defibrillation shocks for ventricular fibrillation; data were recorded using the Laerdal PC Skill Reporting System (Norway). The teams were first subjectively (visually) evaluated by a panel of judges and these evaluations were later reaffirmed using video records. Results: A ∼30s delay was observed between the time of contact and initiation of chest compression in the teams that adopted the American Heart Association (AHA) method compared with those that adopted the European Resuscitation Council (ERC) method. Although the overall quality of chest compressions was very good, in several instances, the hand positions were inappropriate and complete chest recoil was not achieved. The left paddle was incorrectly positioned by all teams. Only 15.8% of the teams were able to deliver shocks with less than 10s of interruption between the chest compressions. Regarding interruption of chest compressions at confirmation of correct tracheal tube placement, among the eight teams that adopted the AHA method, pauses of more than 10s were confirmed in five (62.5%). Conclusions: Significant differences in performance between the AHA and ERC methods were observed. The ERC guidelines were more rational and suitable in terms of actual application than the AHA guidelines. [Copyright &y& Elsevier]

Summary: Aim: Feedback during CPR may facilitate quality in chest compressions, but has also been associated with caregiver complaints such as stiff wrists, the need for more force and increased fatigue. This concern about extra work is, when using the CPREzy™ with its own spring-loaded surface, particularly relevant in the face of an increased number of successive compressions. This manuscript evaluates the objective workloads for caregivers with and without the CPREzy™. Materials and methods: An air pressure driven, piston device was used to generate controlled compressions in a manikin model. The pressure was applied for chest compressions with each of the following: the cylindrical end of the piston, a wooden block as dummy for the CPREzy™, and the CPREzy™ itself. Three manikins with subjectively different spring compliances were selected for the tests. Series of 20 compressions were performed over a wide range of pressures. Results: No additional force is required to achieve a given depth of compression with or without the CPREzy™. However, some additional work is required, ranging from 21 to 26.5%. This work is caused by the longer compression distance associated with the need to compress two springs (e.g. the CPREzy™ and the chest wall) instead of one (e.g. the chest wall). Conclusion: The subjective feeling of increased rescuer fatigue with the CPREzy™ can, at least in part, be attributed to the extra work required for compressing the spring of the CPREzy™. Improved accuracy in chest compression depth is likely to be another, more significant, factor in rescuer fatigue. [Copyright &y& Elsevier]

Summary: Objectives: To develop new methods for studying correlations between the performance and outcome of resuscitation efforts in real-world clinical settings using data recorded by automatic devices, such as automatic external defibrillators (AEDs), and to explore effects of shock timing and chest compression depth in the field. Methods: In 695 records of AED use in the pre-hospital setting, continuous compression data were recorded using AEDs capable of measuring sternal motion during compressions, together with timing of delivered shocks and the electrocardiogram. In patients who received at least one shock, putative return of spontaneous circulation (P-ROSC) was defined as a regular, narrow complex electrical rhythm >40beats/min with no evidence of chest compressions at the end of the recorded data stream. Transient return of spontaneous circulation (t-ROSC) was defined as the presence of a post-shock organized rhythm >40beats/min within 60s, and sustained ≥30s. 2×2 contingency tables were constructed to examine the association between these outcomes and dichotomized time of shock delivery or chest compression depth, using the Mood median test for statistical significance. Results: The probability of P-ROSC for first shocks delivered <50s (the median time) after the start of resuscitation was 23%, versus 11% for first shocks >50s (p =0.028, one tailed). Similarly, the probability of t-ROSC for shorter times to shock was 29%, compared to the 15% for delayed first shocks (p =0.016). For shocks occurring >3min after initiation of rescue attempts, the probability of t-ROSC with pre-shock average compression depth >5cm was more than double that with compression depth <5cm (17.7% vs. 8.3%, p =0.028). For shocks >5min, the effect of deeper compressions increased (23.4% versus 8.2%, p =0.008). Conclusions: Much can be learned from analysis of performance data automatically recorded by modern resuscitation devices. Use of the Mood median test of association proved to be sensitive, valid, distribution independent, noise-resistant and also resistant to biases introduced by the inclusion of hopeless cases. Efforts to shorten the time to delivery of the first shock and to encourage deeper chest compressions after the first shock are likely to improve resuscitation success. Such refinements can be effective even after an unknown period of preceding downtime. [Copyright &y& Elsevier]

Summary: Primary objective: To determine whether using live actors to increase the reality of the scenario improves knowledge retention in Advanced Cardiac Life Support (ACLS) Courses. Main secondary objectives: To determine the effects of age, time since graduation from nursing or medicine, sex, medical specialty, and workplace in knowledge retention. Methods: From December 2004 to October 2005, 19 selected ACLS courses were divided at random in two groups: group A (ACLS courses with conventional manikins plus live actors) and group B (ACLS courses with conventional manikins). The live actors vocalized appropriately to create more realistic scenarios. The participants’ relevant theoretical knowledge was assessed before the course (pre-test), immediately after the course (post-test), and 6 months after the course (final-test). Results: Four hundred and thirty-five participants were recruited and allocated at random allocated to either group A or B. Overall, the data of 225 participants (51.7%; 111 in group A and 114 in group B) who completed the entire sequence of pre-, post-, and final-tests were analysed. On univariate analysis, the use of live actors, workplace, gender, and healthcare provider profession did not affect pre-, post-, and final-test results (p >0.1). The results in all three tests correlated negatively with time since medical or nursing graduation (95% C.I. −0.53 to −0.17, −0.43 to −0.2, and −0.42 to −0.11, respectively, p <0.05) and age (and 95% C.I. −0.56 to −0.21, −0.42 to −0.2, and −0.38 to −0.07, respectively, p <0.05). Conclusion: The use of live actors did not affect knowledge retention in this group. Older age and a longer period since graduation were associated with the worst scores and the lowest levels of knowledge retention. [Copyright &y& Elsevier]

Summary: Objective: To test the hypothesis that laypeople who learn CPR using an 8-min self-instructional DVD acquire a level of skill that is comparable to that achieved with conventional courses. Methods: Forty volunteers used a short DVD with replay facility, and a simple inflatable training manikin, for self-instruction in basic life support. A further 40 volunteers (control group) attended a conventional 1-h instructor-led course. Skill acquisition was measured for each group. Results: After training, the self-instructional group achieved remarkably similar results compared with the control group for all measured skill variables except compression depth, which was significantly greater for the control group. Conclusion: Very short, DVD-based, self-instructional packages may be suitable for more widespread use, including distance-learning and other circumstances in which educational opportunities and resources are limited. [Copyright &y& Elsevier]

Summary: The present study examined the ability of the crew of small fast rescue boats to perform basic life support (BLS) at sea. Tests were undertaken aboard a 67m emergency response and rescue vessel (ERRV), a 9.1m (30ft) and 11.6m (38ft) fast rescue craft (“daughter craft” (DC)). It was hypothesised that the ability to perform BLS on a DC would be significantly impaired when compared with that seen on the ERRV. Nine DC crew volunteered for the study. These tests were undertaken in sea states ranging from 0.5 to 6 (13cm to 4m wave height). Wind speeds ranged between 0 and 35knots. The deterioration observed in the performance of BLS on board the DC compared to that seen on the ERRV was significant (P <0.05) and was due, in part, to a tendency to over-inflate during rescue breathing, and under-compress during BLS when on the DC. Chest compression (CC) was impaired significantly above a sea state 3 (wave height 61–92cm). It is concluded that the performance of BLS on small boats, in particular rescue breathing, is significantly adversely affected by two major factors, motion-induced interruption and early fatigue. As a consequence, the likelihood of conducting fully effective continuous BLS on a small boat in a seaway for any length of time, with a good chance of a successful outcome, is considered to be poor. However, this should not deter rescuers from attempting to make such efforts where practicable. [Copyright &y& Elsevier]

Summary: Context: Termination of resuscitation (TOR) in the field for out-of-hospital cardiac arrest (OHCA) can reduce unnecessary transport to hospital and increase availability of resources for other patients. Objectives: To compare the performance of three TOR guidelines for Basic Life Support-Defibrillator (BLS-D) providers when applied to cardiac arrest patients in the Cardiac Arrest and Resuscitation Epidemiology (CARE) study. Design: This prospective cohort study involved all OHCA patients attended by BLS-D providers in a large urban center. The data analyses were conducted secondarily on these prospectively collected data. Three TOR guidelines proposed by Marsden et al. [BMJ 1995;311:49–51], Petrie [CJEM 2001;3:186–92] and Verbeek et al. [Acad Emerg Med 2002;9:671–8] were applied to show the relationship between the guidelines and actual survival. Results: From 1 October 2001 to 14 October 2004, 2269 patients were enrolled into the study. Thirty-two (1.4%) survived to hospital discharge. For the 3 TOR guidelines, sensitivity was 93.8% (95%CI=79.9–98.3) (Petrie), 81.3% (95%CI=64.7–91.1) (Verbeek) and 90.6% (95%CI=75.8–96.8) (Marsden). Negative predictive value was 99.7% (95%CI=99.0–100.0) (Petrie), 99.6% (95%CI=99.2–99.8) (Verbeek) and 99.8% (95%CI=99.4–99.9) (Marsden). Application of these guidelines would have resulted in transport of 68.4% (Petrie), 31.3% (Verbeek) and 36.1% (Marsden) of cases. The Petrie guidelines would have recommended TOR in two patients who eventually survived. Similarly TOR was recommended in six patients for Verbeek and three patients for Marsden who eventually survived. Conclusion: We found all three TOR guidelines to have high sensitivity and negative predictive value. However the specificity and transport rates varied greatly. Application of any TOR guidelines may be affected by local EMS and population factors which should be considered in any policy decision. [Copyright &y& Elsevier]

Summary: Background: The ‘ABC for life’ programme was designed to facilitate the wider dissemination of basic life support (BLS) skills and knowledge in the population. A previous study demonstrated that using this programme 10–12-year olds are capable of performing and retaining these vital skills when taught by medical students. There are approximately 25,000 year 7 school children in 900 primary schools in Northern Ireland. By using a pyramidal teaching approach involving medical students and teachers, there is the potential to train BLS to all of these children each year. Aims: To assess the effectiveness of a programme of CPR instruction using a three-tier training model in which medical students instruct primary school teachers who then teach school children. Settings: School children and teachers in the Western Education and Library Board in Northern Ireland. Methods: A course of instruction in cardiopulmonary resuscitation (CPR) – the ‘ABC for life’ programme – specifically designed to teach 10–12-year-old children basic life support skills. Medical students taught teachers from the Western Education and Library Board area of Northern Ireland how to teach basic life support skills to year 7 pupils in their schools. Pupils were given a 22-point questionnaire to assess knowledge of basic life support immediately before and after a teacher led training session. Results: Children instructed in cardiopulmonary resuscitation using this three-tier training had a significantly improved score following training (57.2% and 77.7%, respectively, p <0.001). Conclusion: This study demonstrates that primary school teachers, previously trained by medical students, can teach BLS effectively to 10–12-year-old children using the ‘ABC for life’ programme. [Copyright &y& Elsevier]

Summary: Background: Out-of-hospital cardiac arrest (OHCA) is of major medical and public health significance. It also serves as a good indicator in assessing the performance of local emergency medical services system (EMS). There have been arguments for and against the benefits of advanced life support (ALS) over basic life support with defibrillator (BLS-D) for treating OHCA. Aims of the study: The study was conducted to characterise the outcomes of cardiac arrest victims in an Asian metropolitan city; to evaluate the impacts of ALS versus BLS-D services; and to explore the possible patient and arrest factors that may be associated with the observed differences in the outcomes between the two pre-hospital care models. Materials and methods: Taipei is an Asian metropolitan city with an area of 272km2 and a population of 2.65 million. The fire-based BLS-D EMS system was in the process of phasing in ALS capability. While there were 40 BLS-D teams in the 12 city districts, two ALS teams were set up in the central part of the city. In this prospective study, all adult non-traumatic OHCA from September 2003 to August 2004 were included. Patient, arrest, care, and outcome variables for OHCA victims were collected from prehospital run sheets, automatic defibrillators, and emergency department and hospital records. Results: Among 1423 OHCA included in the analysis, 1037 (73%) received BLS-D service, and 386 (27%) received ALS services. The initial shockable rhythms and early bystander CPR were strongly associated with better survival for victims of cardiac arrests. Compared to BLS-D, ALS patients had similar age, sex, witness status, the rate of bystander CPR, and response timeliness but more patients in asystole (84% versus 72%, p =0.005). Patients treated by ALS were more likely to result in significantly higher rates of return of spontaneous circulation (29% versus 21%; OR=1.51 (95% CI 1.15–2.00); p =0.002) and survival to emergency department/intensive care unit admission (23% versus 15%; OR=1.66 (95% CI 1.22–2.24); p =0.001), but there was no difference in the rate of survival to hospital discharge (7% versus 5%; OR=1.39 (95% CI 0.84–2.23); p =0.17). The outcome difference from ALS services was more pronounced among patients in asystole and without bystander CPR. Conclusions: In this metropolitan EMS in Asia, the implementation of ALS services improved the intermediate, but not the final outcomes. Communities with larger populations and lower incidence of initial shockable rhythms than the OPALS study should also prioritise their resources in setting up and optimising systems of basic life support and early defibrillations. Further studies are warranted to configure the optimal care model for combating cardiac arrest. [Copyright &y& Elsevier]

Summary: Background: As 70–80% of cardiac arrests occur at home, widespread training is needed to increase the likelihood of basic life support (BLS) being performed before the arrival of Emergency Medical Services personnel. Teaching BLS in public schools has been recommended to achieve this. Aim: To compare BLS skill retention in school children with adults when using a simple personal resuscitation manikin. Methods: The MiniAnne (Laerdal Medical, Norway) was distributed to 76 pupils (age 12–14 years) in three public schools and to 194 employees (age 22–51 years) in an insurance company. Using the enclosed DVD, the participants carried out a 24min BLS course and took home the manikin for subsequent self-training. After 3 months, skill retention was assessed using the ResusciAnne and the PC Skill reporting System 2.0 (Laerdal Medical, Norway) in a 5min test. A combined score ranging from 12 to 52 points was calculated and in addition, 12 different variables were compared. Results: The combined score was significantly higher in adults (35 points versus 32 points, P =0.0005). The adults performed significantly better than the children in all but four variables. ‘Ventilation–compression ratio’ and ‘hand-position’ were not significantly different. The children performed significantly better in the variables ‘total compressions’ (median 199 versus 154, P =0.0003), and ‘hands-off time’ (median 158.5s versus 188.5s, P <0.0001). Conclusion: Three months after a BLS course, adults had higher overall BLS skill retention scores than school children when using a simple personal resuscitation manikin. [Copyright &y& Elsevier]

Summary: Objective: Better quality bystander first-aid could improve outcome rates for emergency victims significantly. In this case–control study, we hypothesised that expert knowledge presented step-by-step to untrained helpers using a personal digital assistant (PDA), would improve the quality of bystanders basic life support. Method: We confronted 101 lay-helpers with two standard emergency situations. (1) An unconscious trauma victim with severe bleeding. (2) Cardiopulmonary resuscitation (CPR). Performance was assessed using an Objective Structured Clinical Examination (OSCE). One group was supported by a PDA providing visual and audio instructions, whereas the control group acted only with their current knowledge. The expert system was programmed in HTML-code and displayed on the PDA''s Internet browser. Results: The maximum score obtainable was 24 points corresponding to optimal treatment. The control group without the PDA reached 14.8±3.5 (mean value±standard deviation), whereas the PDA supported group scored significantly higher (21.9±2.7, p <0.01). The difference in performance was measurable in all criteria tested and particularly notable in the items: placing in recovery position, airway management and quality of CPR. Conclusion: The PDA based expert system increased the performance of untrained helpers supplying emergency care significantly. Since Internet compatible mobile devices have become widely available, a significant quality improvement in bystander first-aid seems possible. [Copyright &y& Elsevier]

Summary: Study objective: This study evaluates inter-rater reliability and comfort of BLS providers with the application of an out-of-hospital Basic Life Support Termination of Resuscitation (BLS TOR) clinical prediction rule. This rule suggests that continued BLS cardiac resuscitation is futile and can be terminated in the field if the following three conditions are met: (1) no return of spontaneous circulation; (2) no shock given prior to transport; (3) cardiac arrest not witnessed by EMS personnel. Methods: Providers hypothetically applied the rule and rated their comfort level on a five-point Likert-type scale, from “very comfortable” to “very uncomfortable” during the prospective validation of a BLS TOR clinical prediction rule in out-of-hospital cardiac arrest conducted in 12 rural and urban communities [Morrison LJ, Visentin LM, Kiss A, et al. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. New Engl J Med 2006;355(5):478–87]. A Kappa score measured agreement between providers and compared to the correct interpretation of the rule. Results: We compared mean comfort levels of providers who interpreted the rule correctly versus incorrectly. Of 1240 enrolled cases, 1184 (95.5%) had paramedic attendant forms and 1211 (97.7%) had driver forms and 1175 (94.7%) had both. Kappa for interpretation agreement between driver and attendant was 0.90 (95% CI, 0.87–0.92); between attendant and correct interpretation of the BLS TOR clinical prediction rule, 0.88 (95% CI, 0.85–0.91); between driver and correct interpretation of the BLS TOR clinical prediction rule, 0.88 (95% CI, 0.85–0.91). For instances in which both providers applied the rule correctly (607/635 [95.6%]), the providers were significantly more comfortable (χ 2(4)=30.5, p <0.0001) than those instances in which they did not (28/635 [4.4%]. Conclusions: The vast majority of providers were able to apply the BLS TOR clinical prediction rule correctly and were comfortable doing so. This suggests that both reliability and comfort will remain high during routine application of the rule when paramedics are well trained as users of the rule. [Copyright &y& Elsevier]

Summary: Background: Studies show that acquisition and retention of BLS skills is poor, and this may contribute to low survival from cardiac arrest. Feedback from instructors during BLS training is often lacking. This study investigates the effects of continuous feedback from a manikin on chest compression and ventilation techniques during training compared to instructor feedback alone. Materials and methods: A prospective randomised controlled trial. First-year healthcare students at the University of Birmingham were randomised to receive training in standard or feedback groups. The standard group were taught by an instructor using a conventional manikin. The feedback group used a ‘Skillreporter’ manikin, which provides continuous feedback on ventilation volume and chest compression depth and rate in addition to instructor feedback. Skill acquisition was tested immediately after training and 6 weeks later. Results: Ninety-eight participants were recruited (conventional n =49; Skillreporter n =49) and were tested after training. Sixty-six students returned (Skillreporter n =34; conventional n =32) for testing 6 weeks later. The Skillreporter group achieved better compression depth (39.96mm versus 36.71mm, P <0.05), and more correct compressions (58.0% versus 40.4%, P <0.05) at initial testing. The Skillreporter group also achieved more correct compressions at week 6 (43.1% versus 26.5%, P <0.05). Conclusions: This study demonstrated that objective feedback during training improves the performance of BLS skills significantly when tested immediately after training and at re-testing 6 weeks later. However, CPR performance declined substantially over time in both groups. [Copyright &y& Elsevier]

Summary: Recent studies have found that poor cardiopulmonary resuscitation (CPR) is commonly performed in resuscitation attempts, both by health professionals and lay people. One of the contributing factors to poor performance of CPR may be poor initial teaching. This study was conducted to investigate the quality of 14 CPR courses complying with New Zealand Qualifications Authority standards, which includes formal assessment of CPR. While courses taught by the large first aid training organisations in New Zealand had a student to manikin ratio of around 3:1, courses taught by smaller providers had a ratio of over 4:1. During the 4h course, only 20±2min were spent demonstrating CPR, and 26±4min were spent with students practising CPR. The assessment of adult, child and infant CPR took on average less than 2.5min in total. Importantly, in the majority of courses (71%), certification was granted when the CPR technique was performed incorrectly, with both compression depth and compression place being corrected only 57% of the time. Courses only discussed the importance of early defibrillation 57% of the time, and provided limited information on symptoms of acute coronary syndromes. In light of these observations it is suggested that the current style of teaching is unlikely to result in students being able to perform adequate CPR if required in the community. [Copyright &y& Elsevier]

Summary: Background: Less than 1% of the general public know how to assess or manage someone who has collapsed. It has been estimated that if 15–20% of the population were capable of performing cardiopulmonary resuscitation (CPR), mortality of out of hospital cardiac arrest could be decreased significantly. Training basic life support (BLS) skills to school children would be the most cost effective way of achieving this goal and ensuring that a large proportion of the population acquire basic life saving skills. Aims: To assess retention of knowledge of basic life support 6 months after a single course of instruction in cardiopulmonary resuscitation designed specifically for school children. Setting: School pupils in a rural location in one region of the United Kingdom. Methods: A course of instruction in cardiopulmonary resuscitation – the ‘ABC for life’ programme – specifically designed to teach 10–12-year-old school children basic life support skills. The training session was given to school pupils in a rural location in Northern Ireland. A 22 point questionnaire was used to assess acquisition and retention of basic life support knowledge. Results: Children instructed in cardiopulmonary resuscitation showed a highly significant increase in level of knowledge following the training session. While their level of knowledge decreased over a period of 6 months it remained significantly higher than that of a comparable group of children who had never been trained. Conclusion: A training programme designed and taught as part of the school curriculum would have a significant impact on public health. [Copyright &y& Elsevier]