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Background: App-linked real-time feedback-devices for cardiopulmonary resuscitation (CPR) aim to improve laypersons’ resuscitation quality. Resuscitation guidelines recommend these technologies in training settings. This is the first study comparing resuscitation quality of all App-linked feedback-devices currently on market. Methods: A prospective randomised simulation study was performed. After standardised instructions, participants performed 2-minutes compression-only CPR on a manikin without feedback (baseline). Afterwards, participants performed 4 × 2 min CPR with four different feedback devices in randomised order (CorPatch® Trainer, CPRBAND AIO Training, SimCPR®ProTrainer, Relay Response™) (intervention). CPR metrics (chest compression depth (CD), chest compression rate (CR), percentage of correct CD/CR (%), correct hand position, correct chest recoil, and technical preparation-time) were assessed. Devices data were compared to the baseline group using Wilcoxon testing with IBM SPSS (primary outcome). Differences between devices were analysed with ANOVA testing (secondary outcome). Normally distributed data were described as mean ± standard deviation (SD) and non-normally distributed data as Median [Interquartile range (IQR). CPR self-confidence was measured by means of questionnaire before and after feedback devices’ use. Comparison was performed by students t-test. Results: Forty participants were involved. SimCPR®ProTrainer was the only device, which resulted in guideline-compliant chest compressions (Mean ± SD:5.37 ± 0.76) with improved chest compression depth (p

Background: A flipped classroom integrating clinical simulation has been shown to be effective for basic life support (BLS) competencies in nursing students. Cardiopulmonary arrests (CPAs) in pregnant women have a low incidence but high morbidity and mortality. Current trends show an increasing incidence; however, most official university nursing training curricula do not include specific training modules for BLS in pregnant women. This study aims to know the satisfaction and self-confidence of nursing students with respect to a training intervention regarding in BLS in pregnant women. Additionally, it aims to assess the adequacy of this intervention for acquiring the necessary knowledge on the subject. Methods: A cross-sectional study was conducted at the University of Jaen in 2022. Data were collected on sociodemographic factors, previous contact with the topic, and topic knowledge in addition to the use of an SCLS questionnaire to measure satisfaction. Participants took the BLS training (a flipped classroom integrating clinical simulation on this topic) before answering the questionnaire. Results: A total of 136 students participated. The mean score on the BLS questionnaire was 9.10 out of 10 (SD = 1.01). The mean score for the SCLS questionnaire for females was 62.36 (SD = 7.70) and 56.23 (SD = 16.94) for the male group. Age showed a statistically significant association with SCLS score: the score decreased with an increase in age (p < 0.001). Conclusions: The flipped classroom, integrating simulation for BLS in pregnant women, improves self-confidence, satisfaction, and knowledge on the topic. [ABSTRACT FROM AUTHOR]

Limited research exists on the effect of adolescents' affections on the success of cardiopulmonary resuscitation (CPR) training and the adolescents' decision-making skills and practices during an occurrence of cardiac arrest. We aimed to evaluate the effect of CPR training on the knowledge, behaviour and affections of students aged 16–17 years. A pretest-posttest randomised controlled trial was carried out with 115 tenth-grade students from western Turkey. The one group received basic life support (BLS) training, while the other group were given hands-only CPR (HOCPR) training. The study data were collected using a socio-demographic data form, the Positive and Negative Affect Scale (PANAS) and a CPR questionnaire. The median change in positive affect in the BLS group was −2.964; the median in the HOCPR group was −1.206. No significant difference was found between the groups. In the BLS group, the median change in negative affect was −3.649, and the median was 2.568 in the HOCPR group. The change in knowledge scores was higher in the HOCPR group. There was no difference between training methods in affections changes. Both methods reduced students' anxiety about CPR and provided a positive change in their thoughts about intervening in an occurrence. [ABSTRACT FROM AUTHOR]

The use of smartphone applications increases bystander CPR quality as well as the use of telephone CPR protocols. The present prospective, randomized, controlled manikin trial analyses the effects of a smartphone application (PocketCPR©) on CPR quality in a bystander CPR scenario compared to a dispatcher-assisted telephone CPR with the additional use of a metronome and verbal motivation. Methods: 150 laypersons were included to perform 8-minute CPR on a manikin. Volunteers were randomly assigned to one of three groups: (1) dispatcher-assisted telephone CPR (telephone-group), (2) dispatcher-assisted telephone CPR combined with the smartphone-application (telephone + app-group) and (3) dispatcher-assisted telephone CPR with additional verbal motivation ("push harder, release completely," every 20 seconds, starting after 60 seconds) and a metronome with 100 min−1 (telephone + motivation-group). Results: Median compression depth did not differ significantly between the study groups (p = 0.051). However, in the post hoc analysis median compression depth in the telephone + motivation-group was significantly elevated compared to the telephone + app-group (59 mm [IQR 47–67 mm] vs. 51 mm [IQR 46–57 mm]; p = 0.025). The median number of superficial compressions was significantly reduced in the telephone + motivation-group compared to the telephone + app-group (70 [IQR 3–362] vs. 349 [IQR 88–538]; p = 0.004), but not compared to the telephone-group (91 [IQR 4–449]; p = 0.707). In contrast to the other study groups, median compression depth of the telephone + motivation-group increased over time. Chest compressions with correct depth were found significantly more often in the telephone + app-group compared to the other study groups (p = 0.011). Median compression rate in the telephone + app-group was significantly elevated (108 min−1 [IQR 96–119 min−1]) compared to the telephone-group (78 min−1 [IQR 56–106 min−1]; p < 0.001) and the telephone + motivation-group (99 min−1 [IQR 91–101 min−1]; p < 0.001). Conclusions: The use of a smartphone application as well as verbal motivation by a dispatcher during telephone CPR leads to higher CPR quality levels compared to standard telephone CPR. Thereby, the use of the smartphone application mainly shows an increase in compression rate, while increased compression rate with simultaneously increased compression depth was only apparent in the telephone + motivation-group. [ABSTRACT FROM AUTHOR]

Background: In-hospital cardiac arrest is a major cause of death in European countries, and survival of patients remains low ranging from 20% to 25%. Aims: The purpose of this study was to assess healthcare professionals' knowledge on cardiopulmonary resuscitation among university hospitals in 12 European countries and correlate it with the return of spontaneous circulation rates of their patients after in-hospital cardiac arrest. Methods and results: A total of 570 healthcare professionals from cardiology, anaesthesiology and intensive care medicine departments of European university hospitals in Italy, Poland, Hungary, Belgium, Spain, Slovakia, Germany, Finland, The Netherlands, Switzerland, France and Greece completed a questionnaire. The questionnaire consisted of 12 questions based on epidemiology data and cardiopulmonary resuscitation training and 26 multiple choice questions on cardiopulmonary resuscitation knowledge. Hospitals in Switzerland scored highest on basic life support (P =0.005) while Belgium hospitals scored highest on advanced life support (P <0.001) and total score in cardiopulmonary resuscitation knowledge (P =0.01). The Swiss hospitals scored highest in cardiopulmonary resuscitation training (P <0.001). Correlation between cardiopulmonary resuscitation knowledge and return of spontaneous circulation rates of patients with in-hospital cardiac arrest demonstrated that each additional correct answer on the advanced life support score results in a further increase in return of spontaneous circulation rates (odds ratio 3.94; 95% confidence interval 2.78 to 5.57; P <0.001). Conclusion: Differences in knowledge about resuscitation and course attendance were found between university hospitals in 12 European countries. Education in cardiopulmonary resuscitation is considered to be vital for patients' return of spontaneous circulation rates after in-hospital cardiac arrest. A higher level of knowledge in advanced life support results in higher return of spontaneous circulation rates. [ABSTRACT FROM AUTHOR]

Background: The immediate response to cardiac arrest is regarded as the most time-critical intervention. First responders for cardiac arrests in imaging departments are often radiology staff. The study aim was to determine radiology staff members’ confidence in initiating basic life support. Objectives: The objectives of this study included determining the general confidence levels regarding identifying cardiac arrest and initiation of basic life support (BLS) amongst Radiology staff within the studied sites, as well as to identify potential areas of uncertainty. Another objective included identifying what would contribute to increasing levels of confidence and competence in identifying cardiac arrest and initiating BLS. Method: A multi-centre cross-sectional survey was conducted using peer-validated, anonymous questionnaires. Questionnaires were distributed to radiology staff working in public sector hospitals within the Cape Town Metropole West. Due to the limited subject pool, a convenience sample was collected. Data were therefore statistically analysed using only summary statistics (mean, standard deviation, proportions, and so on), and detailed comparisons were not made. Results: We disseminated 200 questionnaires, and 74 were completed (37%). There were no incomplete questionnaires or exclusions from the final sample. Using a 10-point Likert scale, the mean ability to recognise cardiac arrest was 6.45 (SD ± 2.7), securing an airway 4.86 (SD ± 2.9), and providing rescue breaths and initiating cardiac compressions 6.14 (SD ± 2.9). Only two (2.7%) of the participants had completed a basic life support course in the past year; 11 (14.8%) had never completed any basic life support course and 28 (37.8%) had never completed any life support or critical care course. Radiologists, radiology trainees and nurses had the greatest confidence in providing rescue breaths and initiating cardiac compressions from all the groups. Conclusion: The study demonstrated a substantial lack of confidence in providing basic life support in the participating hospital imaging departments’ staff. The participants indicated that regular training and improved support systems would increase confidence levels and improve skills.

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Background: The immediate response to cardiac arrest is regarded as the most time-critical intervention. First responders for cardiac arrests in imaging departments are often radiology staff. The study aim was to determine radiology staff members' confidence in initiating basic life support. Objectives: The objectives of this study included determining the general confidence levels regarding identifying cardiac arrest and initiation of basic life support (BLS) amongst Radiology staff within the studied sites, as well as to identify potential areas of uncertainty. Another objective included identifying what would contribute to increasing levels of confidence and competence in identifying cardiac arrest and initiating BLS. Method: A multi-centre cross-sectional survey was conducted using peer-validated, anonymous questionnaires. Questionnaires were distributed to radiology staff working in public sector hospitals within the Cape Town Metropole West. Due to the limited subject pool, a convenience sample was collected. Data were therefore statistically analysed using only summary statistics (mean, standard deviation, proportions, and so on), and detailed comparisons were not made. Results: We disseminated 200 questionnaires, and 74 were completed (37%). There were no incomplete questionnaires or exclusions from the final sample. Using a 10-point Likert scale, the mean ability to recognise cardiac arrest was 6.45 (SD ± 2.7), securing an airway 4.86 (SD ± 2.9), and providing rescue breaths and initiating cardiac compressions 6.14 (SD ± 2.9). Only two (2.7%) of the participants had completed a basic life support course in the past year; 11 (14.8%) had never completed any basic life support course and 28 (37.8%) had never completed any life support or critical care course. Radiologists, radiology trainees and nurses had the greatest confidence in providing rescue breaths and initiating cardiac compressions from all the groups. Conclusion: The study demonstrated a substantial lack of confidence in providing basic life support in the participating hospital imaging departments' staff. The participants indicated that regular training and improved support systems would increase confidence levels and improve skills. [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]

Introduction: Chest compressions depth and complete chest recoil are both important for high-quality Cardio-Pulmonary Resuscitation (CPR). It has been demonstrated that anthropometric variables affect chest compression depth, but there are no data about they could influence chest recoil. The aim of this study was to verify whether physical attributes influences chest recoil in lay rescuers.Methods: We evaluated 1 minute of compression-only CPR performed by 333 laypersons immediately after a Basic Life Support and Automated External Defibrillation (BLS/AED) course. The primary endpoint was to verify whether anthropometric variables influence the achievement a complete chest recoil. Secondary endpoint was to verify the influence of anthropometric variables on chest compression depth.Results: We found a statistically significant association between weight and percentage of compressions with correct release (p≤0.001) and this association was found also for height, BMI and sex. People who are heavier, who are taller, who have a greater BMI and who are male are less likely to achieve a complete chest recoil. Regarding chest compressions depth, we confirm that the more a person weighs, the more likely the correct depth of chest compressions will be reached.Conclusions: Anthropometric variables affect not only chest compression depth, but also complete chest recoil. CPR instructors should tailor their attention during training on different aspect of chest compression depending on the physical characteristics of the attendee. [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]

Introduction: Basic life support (BLS) with cardiopulmonary resuscitation (CPR) provided at the right time greatly improves survival following cardiac arrest. Adequate knowledge and skills related to BLS are essential requisites for medical students. This study aimed to explore the knowledge, attitudes, and practices related to BLS among undergraduate medical students of a medical college in Tamil Nadu, India. Materials and Methods: This was a descriptive, cross-sectional study conducted among 241 undergraduate medical students of a medical college in Tamil Nadu, between May and July 2012, using a pretested, semi-structured questionnaire devised based on American Heart Association Guidelines for BLS and CPR 2010. Results: The mean knowledge score of the participants was 4.55 ± 1.21 out of a possible high score of 6. The level of knowledge and attitudes related to BLS varied depending on the year of study, and this difference was statistically significant (p<0.05). The knowledge score decreased with increasing duration of training. The higher the year of study, the more positive the participants' attitudes were. Only 12.9% of the participants had ever practised BLS. Twenty-one (21) participants (8.7%) expressed reluctance about performing BLS in a hospital setting, and 57.3% of the participants expressed reluctance about performing BLS in an out-of-hospital setting. Fear of acquiring infection, causing harm to the victim, and lack of confidence were the common causes for participants' reluctance. Conclusions: The study reveals inadequate knowledge and practices related to BLS among students. The differences in knowledge and attitudes among students, depending on the year of study, point to the need for frequent refresher training and motivation of students. [ABSTRACT FROM AUTHOR]

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: Although fatal drowning rarely occurs in swimming pools, this event has a very grave impact on the swimming pool employees, notably when they have been directly involved in the rescue and resuscitation. At the same time, very little data is available on the incidence, causes and outcome of pool drowning. It is important that pool lifeguards understand that a cardiac arrest after drowning is different from the primary cardiac arrest due to an infarction or ventricular fibrillation and that oxygen is the most vital aspect of the resuscitation measures. The use of a pool safety plan and the implementation of a checklist, training in realistic pool-related resuscitation scenarios and record keeping of accidents and near-accidents may be helpful to be better prepared for a drowning incident. [Copyright &y& Elsevier]

Background: Within cardiopulmonary resuscitation external chest compressions (ECC) are of outstanding importance. Frequent training in Basic Life Support (BLS) may improve the performance, but the perfect method or environment is still a matter of research. The objective of this study was to evaluate whether practical performance and retention of skills in resuscitation training may be influenced by the gender composition in learning groups. Methods: Participants were allocated to three groups for standardized BLS-training: Female group (F): only female participants; Male group (M): only male participants; Standard group (S): male and female participants. All groups were trained with the standardized 4-step-approach method. Assessment of participants' performance was done before training (t1), after one week (t2) and eight months later (t3) on a manikin in the same cardiac arrest single-rescuer -scenario. Participants were 251 Laypersons (mean age 21; SD 4; range 18-42 years; females 63%) without previous medical knowledge. Endpoints: compression rate 90-110/min; mean compression depth 38-51 mm. Standardized questionnaires were used for the evaluation of attitude and learning environment. Results: After one week group F performed significantly better with respect to the achievement of the correct mean compression depth (F: 63% vs. S: 43%; p = 0.02). Moreover, groups F and S were the only groups which were able to improve their performance concerning the mean compression rate (t1: 35%; t3: 52%; p = 0.04). Female participants felt more comfortable in the female-only environment. Conclusions: Resuscitation training in gender-segregated groups has an effect on individual performance with superior ECC skills in the female-only learning groups. Female participants could improve their skills by a more suitable learning environment, while male participants in the standard group felt less distracted by their peers than male participants in the male-only group. [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]

Introduction: Effective delivery of cardiopulmonary resuscitation (CPR) and prompt defibrillation following sudden cardiac arrest (SCA) is vital. Updated guidelines for adult basic life support (BLS) were published in 2010 by the European Resuscitation Council (ERC) in an effort to improve survival following SCA. There has been little assessment of the ability of rescuers to meet the standards outlined within these new guidelines. Methods: We conducted a retrospective analysis of the performance of first year healthcare students trained and assessed using either the new 2010 ERC guidelines or their 2005 predecessor, within the University of Birmingham, United Kingdom. All students were trained as lay rescuers during a standardised eight hour ERC-accredited adult BLS course. Results: We analysed the examination records of 1091 students. Of these, 561 were trained and assessed using the old 2005 ERC guidelines and 530 using the new 2010 guidelines. A significantly greater proportion of candidates failed in the new guideline group (16.04% vs. 11.05%; p < 0.05), reflecting a significantly greater proportion of lay-rescuers performing chest compressions at too fast a rate when trained and assessed with the 2010 rather than 2005 guidelines (6.04% vs. 2.67%; p < 0.05). Error rates for other skills did not differ between guideline groups. Conclusions: The new ERC guidelines lead to a greater proportion of lay rescuers performing chest compressions at an erroneously fast rate and may therefore worsen BLS efficacy. Additional study is required in order to define the clinical impact of compressions performed to a greater depth and at too fast a rate. [ABSTRACT FROM AUTHOR]

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]

Background: External chest compressions (ECC) are essential components of resuscitation and are usually performed without any adjuncts in professional healthcare. Even for healthcare professionals during in-hospital and out-of-hospital resuscitation poor performance in ECC has been reported in recent years. Although several stand-alone devices have been developed none has been implemented as a standard in patient care. The aim of this study was to examine if the use of a mechanical device providing visual feedback and audible assistance during ECC improves performance of healthcare professionals following minimal and simplified instructions. Methods: In a prospective, randomized cross-over study 81 healthcare professionals performed ECC for 3 min (in the assumed setting of a secured airway) twice on a manikin (Skillreporter ResusciAnne®, with PC-Skillreporting System Version 1.3.0, Laerdal, Stavanger, Norway) in a mock cardiac arrest scenario. Group 1 (n=40) performed ECC with the device first followed by classic ECC and group 2 (n=41) in the opposite order. Minimal instructions were standardized and provided by video instruction (1 min 38 s). Endpoints were achievement of a mean compression rate between 90 and 110/min and a mean compression depth of 40-50 mm. In addition participants had to answer questionnaires about demographic data, professional experience and recent recommendations for ECC as well as their impression of the device concerning the ease of use and their personal level of confidence. Data were analyzed for group-related and inter-group differences using SAS (Version 9.1.3, SAS Institute, Cary, NC). Results: A total of 81 healthcare professionals regularly involved in resuscitation attempts in pre-hospital or in-hospital settings took part in the study with no differences between the groups: females 35.8% (n=52), emergency medical technicians 32.1% (n=26), anesthesia nurses 32.1% (n=26), physicians (anesthesiology) 45% (n=29). In group 1 33 out of 40 (82.5%; 99.7±4.82/min; 95% confidence interval 95% CI: 98.1-101.2/min) reached the correct range for compression rate and 29/40 (72.5%; 44.0±4.95 mm; 95% CI: 42.4-45.6 mm) the correct compression depth using the assisting device. Afterwards they conducted classic ECC without the device and deteriorated significantly: correct compression rate was achieved by 12/40 (30%, p≤0.0001; 110.6±11.0/min (95% CI: 107.1-114.1/min), while 25/40 (62.5%; 44.5±5.63 mm; 95% CI: 42.6-46.3 mm) met the correct compression depth. Group 2 performed poorer in ECC without assistance and 5/41 (12.2%; 104.5±21.35/min; 95% CI: 97.8-111.3/min) reached the correct rate whereas 21/41 (51.2%; 39.6±7.61 mm; 95% CI: 37.2-42.0 mm) compressed to the appropriate depth. Using the device there was a significant improvement in the second evaluation with 34/41 (82.9%, p≤0.0001; 101.7±4.68/min; 95% CI: 100.2-103.2/min) reaching the correct rate and 36/41 (87.8%, p≤0.0001; 43.9±4.16 mm; 95% CI: 42.6-45.2 mm) the correct depth. Conclusions: The tested device is easy to use after instruction of less than 3 min and improves ECC performance of healthcare professionals in simulated cardiac arrest with respect to compression depth as well as compression rate. [ABSTRACT FROM AUTHOR]

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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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]

Summary: Aim of the study: External chest compression (ECC) is an essential part of cardiopulmonary resuscitation and usually performed without any adjuncts. Although different supportive devices have been developed, none have yet been implemented as a standard procedure to guide rescuers in resuscitation. This study investigates the effects of the CPREzy™-pad on ECC performed by first year medical students during simulated cardiac arrest. Materials and methods: Two hundred and two subjects were randomised and asked to perform 5min of single-rescuer-CPR. Group 1 (n =111) was taught classic ECC, followed by ECC with the CPREzy™ and was tested in ECC with the CPREzy™. Group 2 (n =91) was taught and tested in classic ECC only. One week later each group was divided: Group 1A was tested in ECC with the CPREzy™ again; Group 1B was tested in classic ECC. Group 2A was taught and tested in ECC with CPREzy™; Group 2B was tested in classic ECC again. Primary endpoints were compression rate (90–110/min) and compression depth (40–50mm). Results: Comparing groups 1 and 2, ECC was significantly superior with CPREzy™ (correct rate: 93.7% versus 19.8%, p ≤0.01; depth: 71.2% versus 34.1%, p ≤0.01). The group tested with CPREzy™ initially 1 week later (2A; n =36) improved significantly in correct compression rate (19.8% versus 88.9%, p ≤0.01) and compression depth (34.1% versus 75.0%, p ≤0.02). The control-group (2B; n =55) without CPREzy™ demonstrated poor performance in both evaluations (correct rate: 19.8% versus 25.5%, depth: 34.1% versus 43.6%). Conclusion: CPREzy™ as a simple portable and re-usable device is able to improve performance of ECC in simulated cardiac arrest. [Copyright &y& Elsevier]

Summary: Objectives: The aim of our study was to evaluate the effect of an automated external defibrillation (AED) training programme on the knowledge, attitudes and application of BLS and AED use in young people of secondary school age in Manchester, United Kingdom. Method: Students from two schools who had piloted Opportunities for Resuscitation and Citizen Safety (ORCS) in the academic year 2004/2005 volunteered to partake in the study. This ‘ORCS intervention’ group was compared against a control group, which consisted of students who had no formal training in resuscitation nor, to our knowledge, any other form of life support training during their time at secondary school. All students were assessed and scored on their knowledge and performance of the BLS algorithm (in accordance with the UK Resuscitation Council (‘Resuscitation Guidelines for the Citizen’) and the use of a trainer defibrillator on a fictional cardiac arrest scenario. Results: We compared 34 ORCS-trained students with 25 control students, all aged between 13 and 16 years. Approximately, twice as many ORCS-trained students than the control students performed many parts of the algorithm correctly, such as checking for danger, checking for response, opening the airway and checking for breathing. More than three times as many ORCS-trained students than controls correctly performed CPR (50% versus 12% of students). As expected, the use of the AED was the part of the algorithm performed worst, but was performed correctly by six times as many ORCS students as controls (27% versus 4% of students). Conclusions: This study demonstrates that training through the ORCS scheme has a positive influence on the ability of secondary school teenagers to perform emergency life support (ELS), but particularly in their ability to deploy an AED and perform CPR. [Copyright &y& Elsevier]

Summary: Objective: Evidence supports that increasing the balance of “hands-on” CPR may improve survival in ventricular fibrillation out-of-hospital cardiac arrest (OHCA). We assessed whether training and/or AED reconfiguration was associated with an increase in the proportion of time during which CPR was performed between first and second stacks of shocks. Methods: The investigation was a cohort study of 291 persons who suffered ventricular fibrillation OHCA and were treated with at least two stacks of AED shocks by emergency medical services (EMS) first-tier responders. In January 2003, first-tier providers were retrained regarding the importance of CPR. In addition, a subset of AEDs was reconfigured to remove continuous fibrillation detection and its associated voice prompts as to be comparable with other AED models. The amount of time spent on CPR was assessed through review of AED electronic and audio recordings to compare the pre-intervention (n =241) and post-intervention periods (n =50). Results: The proportion of time spent performing hands-on CPR between first and second stacks of shocks was 0.40 in the pre-intervention period compared to 0.51 in the post-intervention period (p =0.001). The difference was greatest for AEDs where EMS was retrained and the AED reconfigured (0.33 versus 0.50, p =0.01). No difference in survival was detected between the pre- and post-intervention periods (24.9% versus 28.0%, p =0.65). Conclusions: An intervention consisting of retraining and AED reconfiguration was associated with an increase in the proportion of time spent performing CPR between first and second stacks of shocks by first-tier EMS. Whether this increase improves patient outcomes requires additional study. [Copyright &y& Elsevier]

Summary: Purpose: The feasibility and acceptance of providing sudden cardiac arrest survivors with life supporting first aid training and automated external defibrillators (AEDs) at their homes is unknown. Preliminary experiences are reported here. Methods: Trained medical students provided life supporting first aid courses including AED training to cardiac arrest survivors. Patients were asked to invite relatives and friends to such training sessions at their home. Laerdal Little Anne™ and Heartstart™ AED Trainer were used. An AED was placed at the patients’ disposal. A refresher course took place 1 year later. Questionnaires were used to evaluate the project. Results: Since 1999, 88 families have been trained and provided with an AED. Immediately after the training 90% (66% “agree”, 24% “maybe yes”) believed they would perform first aid correctly, 1 year later 98% did so (68% “agree”, 29% “maybe yes”) (p =0.03). Families considered feeling much safer having an AED at home. The handling of an AED was regarded to be easy and AEDs would even be used on strangers. Only on one occasion an AED was used in a real emergency situation. Conclusion: Providing patients and relatives with life support first aid and AED training at their homes is feasible and has raised no major objections by the family members. All have considered handling of an AED much simpler than providing basic life support and therefore none think that it would be a major problem to use it in case of an emergency. This still has to be proven. [Copyright &y& Elsevier]

Summary: Background: Bystander basic life support (BLS) is an important part of cardiopulmonary resuscitation (CPR) and improves outcome after out-of-hospital cardiac arrest. However, the general population has poor BLS skills. Several training initiatives could be used to improve this situation and the challenge is to find the most efficient one. Aims: To compare the efficiency of a 24min instruction using a DVD-based self-training BLS course combined with a simple, take-home resuscitation manikin to a conventional 6h course for teaching BLS to laypersons. Methods: In total, 238 laypersons (age 21–55 years) without previous BLS-training were allocated into two groups: one group received 24min of instruction using a DVD-based instruction tool on a big screen combined with a BLS self-training device, Laerdal MiniAnne manikin (MAM), before taking home the instruction material for subsequent self-training. The second group attended a conventional 6h BLS course (6HR). After 3 months BLS skills were assessed on a Laerdal ResusciAnne manikin using the Laerdal PC Skill reporting System, and a total score was calculated. Results: There was no significant difference between groups in BLS performance using the total score. Assessment of breathing was performed significantly more often in the 6HR-group (91% versus 72%, P =0.03). In the MAM-group, average inflation volume and chest compression depth were significantly higher (844mL versus 524mL, P =0.006, and 45mm versus 39mm, P =0.005). Conclusions: When assessed after 3 months, a 24min DVD-based instruction plus subsequent self-training in BLS appears equally effective compared to a 6h BLS course and hence is more efficient. [Copyright &y& Elsevier]

Summary: Background: Good scientific evidence is scarce in relation to the effectiveness of different methods of teaching basic life support (BLS) to the general public. In order to test new courses or methods a reference course is needed as a comparative standard. Objective: To propose a reference BLS provider course that can be used as a comparator when testing new courses or teaching methods. Methods: All national resuscitation councils that are represented in the European Resuscitation Council (ERC) were sent a questionnaire about the BLS provider courses run by them or under their auspices. Results: Sixteen national resuscitation councils responded to the enquiry. Their responses regarding organisation, structure, content and methods of the courses were found to be remarkably consistent between European countries. Few issues had a high variance. Conclusions: Based on the responses received, a reference BLS provider course for lay persons is suggested as a tool for research. The course duration is 3h 15min (excluding breaks), with 2h 15min practice time for the participants, 30min for theory and 20min for practical demonstrations by the instructor. A manual is distributed at the start of the course. The ratio of instructors to participants is one to six. The lectures are interactive between the instructor and the participants. Cardiopulmonary resuscitation (CPR) is practised on manikins in groups of six. A formal BLS scenario test may be held at the end of the course as part of a research study or if the candidates so request. It is suggested that by using this reference course during research into lay person BLS teaching, it will be easier to make comparisons between different studies. [Copyright &y& Elsevier]