Search

While the importance of lifeguards in providing immediate and effective basic life support (BLS) in drowning has been well reported, not a lot is known about how lifeguards perceive the relative value of CPR as a lifeguard skill, their training in it, and the likelihood of resuscitation being successful. A self-complete questionnaire was done by 252 volunteer surf lifeguards at 16 surf beaches in the Greater Auckland NZ region. Results show that most lifeguards (65%) had received training in the 3 months before the survey, 83% were willing to perform CPR, few (9%) had used CPR in an emergency, and many had a realistic expectation of the likelihood of CPR being successful. Recall of CPR compression rates (86%) was very good but initial steps at an emergency scene were less accurately recalled. Ways to address the misconceptions reported in the survey through enhanced training programs are discussed. [ABSTRACT FROM AUTHOR]

Abstract: Background: Non-invasive monitoring of cerebral perfusion and oxygen delivery during cardiac arrest is not routinely utilized during cardiac arrest resuscitation. The objective of this study was to investigate the feasibility of using cerebral oximetry during cardiac arrest and to determine the relationship between regional cerebral oxygen saturation (rSO2) with return of spontaneous circulation (ROSC) in shockable (VF/VT) and non-shockable (PEA/asystole) types of cardiac arrest. Methods: Cerebral oximetry was applied to 50 in-hospital and out-of-hospital cardiac arrest patients. Results: Overall, 52% (n =26) achieved ROSC and 48% (n =24) did not achieve ROSC. There was a significant difference in mean±SD rSO2% in patients who achieved ROSC compared to those who did not (47.2±10.7% vs. 31.7±12.8%, p <0.0001). This difference was observed during asystole (median rSO2 (IQR) ROSC versus no ROSC: 45.0% (35.1–48.8) vs. 24.9% (20.5–32.9), p <0.002) and PEA (50.6% (46.7–57.5) vs. 31.6% (18.8–43.3), p =0.02), but not in the VF/VT subgroup (43.7% (41.1–54.7) vs. 42.8% (34.9–45.0), p =0.63). Furthermore, it was noted that no subjects with a mean rSO2<30% achieved ROSC. Conclusions: Cerebral oximetry may have a role as a real-time, non-invasive predictor of ROSC during cardiac arrest. The main utility of rSO2 in determining ROSC appears to apply to asystole and PEA subgroups of cardiac arrest, rather than VF/VT. This observation may reflect the different physiological factors involved in recovery from PEA/asytole compared to VF/VT. Whereas in VF/VT, successful defibrillation is of prime importance, however in PEA and asytole achieving ROSC is more likely to be related to the quality of oxygen delivery. Furthermore, a persistently low rSO2 <30% in spite of optimal resuscitation methods may indicate futility of resuscitation efforts. [Copyright &y& Elsevier]

Post-resuscitation myocardial dysfunction is an important cause of death in the intensive care unit after initially successful cardiopulmonary resuscitation (CPR) of pre-hospital cardiac arrest (CA) patients. Volatile anaesthetics reduce ischaemic–reperfusion injury in regional ischaemia in beating hearts. This effect, called anaesthetic-induced pre- or postconditioning, can be shown when the volatile anaesthetic is given either before regional ischaemia or in the reperfusion phase. However, up to now, little data exist for volatile anaesthetics after global ischaemia due to CA. Therefore, the goal of this study was to clarify whether Sevoflurane improves post-resuscitation myocardial dysfunction after CA in rats. Following institutional approval by the Governmental Animal Care Committee, 144 male Wistar rats (341±19g) were randomized either to a control group or to one of the 9 interventional groups receiving 0.25 MAC, 0.5 MAC or 1 MAC of Sevoflurane for 5min either before resuscitation (SBR), during resuscitation (SDR) or after resuscitation (SAR). After 6min of electrically induced ventricular fibrillation CPR was performed. Before CA (baseline) as well as 1h and 24h after restoration of spontaneous circulation (ROSC), continuous measurement of ejection fraction (EF), and preload adjusted maximum power (PAMP) as primary outcome parameters and end systolic pressure (ESP), end diastolic volume (EDV) and maximal slope of systolic pressure increment (dP/dt max) as secondary outcome parameters was performed using a conductance catheter. EF was improved in all Sevoflurane treated groups 1h after ROSC in comparison to control, except for the 0.25 MAC SDR and 0.25 MAC SAR group (0.25 MAC SBR: 38±8, p =0.02; 0.5 MAC SBR: 39±7, p =0.04; 1 MAC SBR: 40±6, p =0.007; 0.5 MAC SDR: 38±7, p =0.02; 1 MAC SDR: 40±6, p =0.006; 0.5 MAC SAR: 39±6, p =0.01; 1 MAC SAR: 39±6, p =0.002, vs. 30±7%). Twenty-four hours after ROSC, EF was higher than control in all interventional groups (p <0.05 for all groups). EF recovered to baseline values 24h after ROSC in all SBR and SAR groups. PAMP was improved in comparison to control (4.6±3.0mW/μl2) 24h after ROSC in 0.5 MAC SBR (9.4±6.9mW/μl2, p =0.04), 1 MAC SBR (8.9±4.4mW/μl2, p =0.04), 1 MAC SDR (8.0±5.7mW/μl2, p =0.04), and 1 MAC SAR (7.3±3.5mW/μl2, p =0.04). ESP, EDV, and dP/dt max was not different from control 1h as well as 24h after ROSC with the exception of 1 MAC SDR with a reduced ESP 1h after ROSC (89±16 vs. 103±22mmHg, p =0.04). Sevoflurane treatment did not affect survival rate. This animal study of CA and resuscitation provides the hypothesis that pharmacological pre- or postconditioning with the volatile anaesthetic Sevoflurane – administered before CA, during resuscitation or after ROSC – results in an improved myocardial inotropy 24h after ROSC. Sevoflurane treatment seems to improve EF even in the early phase of reperfusion 1h after ROSC. Therefore further targeted studies on the optimal dose and time point of administration of Sevoflurane in cardiopulmonary resuscitation seem to be worthwhile (Institutional protocol number: 35-9185.81/G-24/08). [ABSTRACT FROM AUTHOR]

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: This study assessed the level of agreement on CPR decisions among intensive care doctors and specialist physicians and surgeons, and the barriers to documenting do not attempt resuscitation (DNAR) orders for ward patients during Medical Emergency Team (MET) calls. Methods: We prospectively assessed all patients having MET calls for 11 months. If the intensive care doctor on the MET considered a DNAR order appropriate for the patient, the primary care clinician was contacted to: (1) confirm agreement or disagreement with a DNAR order and (2) give reasons as to why a DNAR order was not considered or documented prior to the MET call. Results: In the study period, the MET attended 1458 patients. A DNAR order was considered appropriate in 129 cases. In 116 (90%), the primary care clinician agreed with a DNAR order at the time of the MET. Common reasons given by primary care clinicians for not documenting DNAR orders included acute or unexpected deterioration (22.5%), awaiting family discussion (22.5%), actively treating the patient for a reversible condition (17.1%), not knowing the patient well enough (10.9%) and resuscitation status not yet discussed by team (10.9%). Conclusions: This study shows a high level of agreement on DNAR orders among intensive care doctors, physicians and surgeons for deteriorating ward patients. Barriers to timely documentation need to be addressed. Delay in documentation and communication of DNAR orders is common. The MET system provides an opportunity to identify patients for whom a DNAR order should be considered. [Copyright &y& Elsevier]

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: 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: Context: A well-suited e-learning program might be a feasible strategy to maintain competence following a resuscitation course. Aim: This study had 2 aims: (1) to examine the effect of an e-learning program as a booster of competence acquired from an Advanced Life Support (ALS) course. (2) To identify factors related to the use of the e-learning program. Materials and methods: The study contained two parts pertaining to the two aims. The first part was a prospective single blinded randomised controlled study on junior doctors. The intervention was the monthly use of an e-learning program during one year and effect was measured as ALS-competence, a composite of a knowledge and skills test. The second part was a telephone interview of the intervention group. An interview guide was constructed based on existing knowledge of e-learning. In order to identify factors explaining the use of e-learning a univariate correlation was used to select significant variables to be included in a multiple regression analysis. Results: Of the 134 invited to participate, 103 accepted the invitation. There were 79/103 (77%) participants, 40/51 in the intervention group and 39/52 in the control group. There was no difference between the groups with regards to ALS competence. Only ‘social interaction’ was an individually significant factor influencing the use of the e-learning program. Conclusions: This study did not demonstrate an effect of an e-learning program as a booster of competence acquired from an ALS course. The primary factor influencing the use of e-learning was the lack of social interaction. [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]

Summary: Background: In 2005 the European Resuscitation Council (ERC) published a revised version of the guidelines for Advanced Life Support (ALS). One of the aims was to reduce the time without chest compression in the first period of cardiac arrest (no-flow-time; NFT). We evaluated in a manikin study the influence on NFT using the single use laryngeal tube with suction option (LTS-D) compared to single use I-gel for emergency airway management. Methods: A randomised prospective study with 200 paramedics who performed standardised simulated cardiac arrest management in a manikin. Results: The use of the LTS-D did not significantly reduce NFT compared with the I-gel (104.7s vs. 105.1s; p >0.05). The LTS-D was inserted as fast as the I-gel (10.4s vs. 9.3s; p >0.05). The LTS-D was correctly positioned by 98% of the participants on the first attempt compared to 96% with the I-gel. During the cardiac arrest simulation, establishing and performing first ventilation took an average of 40.5s with the LTS-D compared to 40.9s with the I-gel. Conclusion: In our manikin study, NFT was comparable using the LTS-D and the I-gel. Therefore, for personnel not experienced in tracheal intubation, the LTS-D and the I-gel seem to be equal alternatives in establishing the airway during cardiac arrest. However, relevant clinical studies are appropriate because any change in guidelines in this area must be based on clinical evidence. [Copyright &y& Elsevier]

Summary: Aims of study: To objectively evaluate how effectively children can perform cardiopulmonary resuscitation CPR) 2 months after a single, 2h training session and establish whether or not their performance is affected by the ratio of external chest compressions to ventilations used. Methods: Eighty-five schoolchildren aged 10–11 years old were given a 2-h CPR training programme. After 2 months they were randomised into two groups and asked to perform CPR on a resuscitation skills reporter manikin for 3min at a ratio of 30:2 followed by 5min rest, then for 3min at 15:2 (or vice versa). Chest compression depths and ventilation volumes were recorded on a laptop computer and analysed using the Hills and Armitage crossover trial design. Results: The school children were found to be capable of performing effective CPR 2 months after a single training session. In both groups the percentage of chest compressions, of depth recommended by current CPR guidelines, was greater when the 15:2 ratio was being used (P <0.001). The average chest compression depth was significantly greater when the children were performing CPR at a ratio of 15:2 (P <0.001). The compression to ventilation ratio used did not affect the average volume or percentage of effective ventilations given. However, in both groups, the ventilation variables showed enhanced performance during the second period of CPR. Conclusions: Children as young as 10–11 years are capable of performing effective CPR after a single, 2h training session in cardiopulmonary resuscitation given in school. This age group are able to achieve greater depth of chest compressions, when using a ratio of 15:2 rather than 30:2. [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: Objective: Both ventilations and compressions are important for victims of prolonged cardiopulmonary resuscitation (CPR) and asphyxial arrest. Dispatch assistance increases bystander CPR, but the quality of dispatcher-assisted CPR (DA-CPR), especially rescue breathing, remains unsatisfactory. This study was conducted to assess the impact of adding interactive video communication to dispatch instructions on the quality of rescue breathing in simulated cardiac arrests. Methods: In this simulation-based study, adults without CPR training within 5 years were recruited between April and July 2007 and randomized to receive dispatch assistance with either voice instruction alone (voice group, n =53) or interactive voice and video instruction (video group, n =43) via a video cell phone. The quality of rescue breathing was evaluated by reviewing the videos and mannequin reports. Results: Subjects in the video group were more likely to open the airway correctly (95.3% vs. 58.5%, P <0.01) and to lift the chin properly (95.3% vs. 62.3%, P <0.01), but had similar rates of head-tilt (95.3% vs. 84.9%, P =0.10). Volunteers in the video group had larger volume of ventilation (median volume 540ml vs. 0ml, P <0.01), greater possibility to sustain an open airway (88.4% vs. 60.4%, P <0.01) and a tendency towards better nose-pinch (97.7% vs. 86.8%, P =0.06). The video group spent longer time to open the airway (59s vs. 56s, P <0.05) and to give the first rescue breathing (139s vs. 102s, P <0.01). Conclusion: Adding video communication to dispatch instructions improved the quality of bystander rescue breathing, including higher proportion of airway opened, and larger volume of ventilation delivered, in simulated cardiac arrests. [Copyright &y& Elsevier]

Summary: Objective: We reassessed 1-month survival of patients with witnessed out-of-hospital cardiac arrest (OHCA) of cardiac origin with ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) in Osaka, Japan, and identified factors associated with 1-month survival using updated data from 1998 to 2004 collected based on the Utstein Style. Methods: Using the Utstein Osaka Project database, we analyzed 1028 cases which met the following criteria: (1) patient age 18 years or older; (2) presumed cardiac origin based on the definition of the Utstein Style; (3) witnessed by citizens; (4) VF or pulseless VT at the time of arrival of the ambulance. The main outcome measure was survival at 1 month after collapse. Variables to develop a predictive model for 1-month survival were selected by stepwise logistic regression. Results: Survival at 1 month was 19.6%. Factors retained in the final logistic regression were age, sex, type of witness, and time interval from (a) ambulance call receipt to cardiopulmonary resuscitation (CPR) by the ambulance crew; (b) ambulance call to defibrillation; (c) CPR by the ambulance crew to hospital arrival. Area under the receiver-operating characteristic curve for the model developed with the six variables was 0.738 and Hosmer–Lemshow goodness-of-fit p-value was 0.94. Conclusion: We successfully developed a model to estimate the probability of 1-month survival using variables easy to collect in the early phase of resuscitation, and this model would help physicians and family members predict the likelihood of 1-month survival of OHCA patients on admission. [Copyright &y& Elsevier]

Summary: We report on a study designed to compare the relative efficacy of manual CPR (M-CPR) and automated mechanical CPR (ACD-CPR) provided by an active compression–decompression (ACD) device. The ECG signals of out-of-hospital cardiac arrest patients of cardiac aetiology were analysed just prior to, and immediately after, cardiopulmonary resuscitation (CPR) to assess the likelihood of successful defibrillation at these time points. The cardioversion outcome prediction (COP) measure previously developed by our group was used to quantify the probability of return of spontaneous circulation (ROSC) after counter-shock and was used as a measure of the efficacy of CPR. An initial validation study using COP to predict shock outcome from the patient data set resulted in a performance of 60% specificity achieved at 100% sensitivity on a blind test of the data. This is comparable with previous studies and provided confidence in the robustness of the technique across hardware platforms. Significantly, the COP marker also displayed an ability to stratify according to outcomes: asystole, ventricular fibrillation (VF), pulseless electrical activity (PEA), normal sinus rhythm (NSR). We then used the validated COP marker to analyse the ECG data record just prior to and immediately after the chest compression segments. This was initially performed for 87 CPR segments where VF was both the pre- and post-CPR waveform. An increase in the mean COP values was found for both CPR types. A signed rank sum test found the increase due to manual CPR not to be significant (p >0.05) whereas the automated CPR was found to be significant (p <0.05). This increase was larger for the automated CPR (1.26, p =0.024) than for the manual CPR (0.99, p =0.124). These results indicate that the application of CPR does indeed provide beneficial preparation of the heart prior to defibrillation therapy whether manual or automated CPR is applied. The COP marker shows promise as a definitive, quantitative determinant of the immediate positive effect of both types of CPR regardless of the details of use. In work of a more exploratory nature we then used the validated COP marker to analyse the ECG pre- and post-CPR for all rhythm types (212 traces). We show a significant increase in the COP measure (p <0.001 in both cases) as indicated by a shift in the median COP marker distribution values. This increase was more pronounced for automated ACD-CPR than for manual CPR. However, a detailed statistical analysis carried out between the groups adjusted for pre-CPR value showed no significant difference between the two methods of CPR (p =0.20). Similarly, adjusting for length of CPR showed no significant difference between the groups. Secondary, subgroup analysis of the ECG according to the length of time for which CPR was performed showed that both types of CPR led to an increase in the likelihood of successful defibrillation after increasing durations of CPR, however results were less reliable after longer periods of continuous CPR. [Copyright &y& Elsevier]

Abstract: Cardiopulmonary resuscitation (CPR) provides possible survival from otherwise fatal cardiopulmonary collapse. Termination guidelines have been developed for use when resuscitation has no potential benefit for a victim. The purpose of this prospective cohort study was to determine if unwitnessed collapse combined with no-bystander cardiopulmonary resuscitation would support a decision to terminate attempted resuscitation. There were 541 patients analyzed during 6 months, with functional neurological survival the outcome of interest. There were no functional neurological survivors at hospital discharge among the 180 victims in the unwitnessed, no-bystander CPR subgroup (95% confidence interval [CI] 0.0%–2.1%). Functional neurological survival for witnessed collapse, bystander CPR was 6.0% (95% CI 2.8%–12.5%), for witnessed collapse, no-bystander CPR was 3.8% (95% CI 1.9%–7.7%), and for unwitnessed collapse, bystander CPR 1.3% (95% CI 0.2%–6.9%). With confirmation by further studies, unwitnessed collapse and lack of bystander CPR may be a practical addition to resuscitation termination guidelines. [Copyright &y& Elsevier]

Summary: Pneumopericardium is the least common form of air leak in infants. A tension pneumopericardium is even more infrequent but associated with a very high mortality rate. We describe the case of an unsuccessful resuscitation in a preterm infant due to a pneumothorax and tension pneumopericardium. Despite relatively mild pressure ventilation the patient developed massive pulmonary interstitial emphysema. The extra-alveolar air spread from the interstitium towards the mediastinal space (Macklin effect) and caused a pneumothorax and pneumopericardium, which evolved towards a tension pneumopericardium after a traumatic mechanical procedure. The infant deteriorated acutely. Despite prompt pleural drainage there were no signs of recovery at any time. Postmortal examination revealed a tension pneumopericardium and massive interstitial pulmonary emphysema, which was not obvious on radiographical investigation. In cases of acute deterioration of a ventilated neonate, one should always rule out pneumothorax. If the patient does not recover after pleural drainage and cardiac resuscitation a (tension) pneumopericardium should be considered. [Copyright &y& Elsevier]

Summary: Background: Analysis of the electrocardiogram (ECG) can to a certain extent predict if a cardiac arrest patient in ventricular fibrillation will get return of spontaneous circulation (ROSC) if defibrillated. The accuracy of such methods determines how useful it is clinically and for retrospective analysis. Methods and results: We have tested the accuracy of a new shock outcome prediction algorithm that is the first to use an updating algorithm capable of learning from previous shocks within a resuscitation effort. The algorithm relies on known predictive features from the pre-shock ECG, but for each delivered shock it re-estimates the patient-dependent relationship between predictive feature value and probability of ROSC by incorporating the information from the already performed shocks. The predictive features mean-slope, median-slope, cardioversion-outcome-predictor and amplitude-spectrum-analysis originally had areas under the receiver operating characteristics curve of 0.843, 0.846, 0.837 and 0.819, respectively. The improvements in areas after applying the algorithm were (bootstrap estimate of mean improvement, 95% confidence interval in parentheses): mean-slope, 0.019 (0.00036, 0.042); median-slope, 0.024 (0.0013, 0.048); cardioversion-outcome-predictor, 0.021 (0.0010, 0.051); amplitude-spectrum-analysis, 0.026 (0.0016, 0.051). The predictions for the first shock to each patient were not included when calculating the areas, as for the first shocks the new algorithm has no previous shocks to learn from and give predictions identical to those of the original features. Conclusions: It is possible to improve current shock prediction methods by using an updating algorithm capable of learning from previous shocks within a resuscitation effort. [Copyright &y& Elsevier]

Summary: Aim of the study: Endotracheal intubation is the preferred method to ensure proper artificial ventilation. Early detection of esophageal intubation is important for an individual patient''s outcome. The aim of the study was to see if impedance measurements can be used to detect esophageal intubation, using the impedance measurement system of an experimental defibrillator. Materials and methods: Patients who died at the emergency department of a tertiary care hospital were eligible to be studied. After death was declared, patients were ventilated with a predefined tidal volume alternately via the conventional tracheal tube and via an additionally tube placed into the esophagus. The lowest and respectively highest median impedance amplitude for the first three ventilations was used as cut-off to calculate predictive values. Results: We enrolled 10 patients (mean age 65 years (S.D. 14), 7 male) of whom 9 underwent CPR prior to death, 30% of the patients had a BMI>30. Severe lung-edema was present in 2 cases. The lowest tracheal impedance value was 0.736Ω and the highest esophageal was 0.496Ω. A ROC curve for this individualised approach gave an area under the curve of 1 (95% CI 0.001, 0.249). Conclusion: There is a large and significant reduction in transthoracic impedance when the tube is malpositioned in the esophagus. It may therefore be feasible to detect malintubation via thoracic impedance changes as an aid to improve the survival of critical ill patients. Further investigations on a larger population are needed. [Copyright &y& Elsevier]

Summary: Objectives: To examine to what extent the type of emergency medical transportation influences the physical response of advanced life support providers. Background: Providing external chest compression during resuscitation is physically exhausting. If the decision is made to bring the patient to a hospital undergoing resuscitation procedures, there are usually two options for transportation: ambulance vehicles or helicopters. There should be discussion on deciding which means of transportation should be preferred, because there is evidence that the quality of rescuers performance influences patient''s outcome. Methods: The study was a randomised crossover trial comparing physical strain on 11 European Resuscitation Council (ERC) approved healthcare professionals during external chest compression in different environments: (a) moving ambulance vehicle vs. (b) flying helicopter, and both compared to (c) staying at the scene (control). Main outcome measures: Difference in heart rate to systolic blood pressure ratio after 8min of external chest compression. Secondary outcomes were BORG-rate of perceived exertion scale, blood pressure, serum lactate, and a Nine Hole Peg Test. Results: Mean heart rate to systolic blood pressure ratio was 0.89±0.21 in the ambulance vehicle compared to 1.01±0.21 in the flying helicopter (p =0.04) There were no significant differences in the secondary outcome parameters. Perceived exertion increased by resuscitation time in all groups. Conclusion: External chest compression CPR is possible in a flying helicopter as it is in a moving ambulance vehicle. There is no clinical relevant difference in physical strain during ALS between a flying helicopter and a moving ambulance car. As would be expected, the exertion increases with duration of CPR. [Copyright &y& Elsevier]

Summary: Aim of the study: : A massive cardiopulmonary resuscitation (CPR) training programme is continued in most hospitals to make hospital personnel ready to take action in cases of cardiac arrest. Motivated course participants learn more and perform better than unmotivated course participants. This study investigates whether hospital personnel are motivated to participate in CPR courses and whether motivation correlates with important assumptions in adult learning. Materials and methods: : A survey measuring learning motivation via the MSLQ instrument was performed among 361 hospital personnel before attending a CPR course. Assumptions of adult learning were identified and data were analysed in relation to these assumptions. Results: : Hospital personnel are generally motivated for learning CPR. Respondents who had been prepared for the course, who had participated in the decision about attending the course, who were working in high-risk area for cardiac arrest or were nursing personnel working in long-time close contact with patients were more motivated to CPR training than other hospital personnel. It seems like motivation correlates with adult learning assumptions such as the learners need to know, the learners self-concept, readiness to learn and orientation to learning. Conclusion: : This study supports the assumption that CPR training should be based on an adult learning model. As preparedness, participation, readiness and relevance seem to be key factors, we may want to include these factors when training hospital personnel in CPR skills. [Copyright &y& Elsevier]

Summary: Objective: The quality of early bystander CPR appears important in maximizing survival. This trial tests whether explicit instructions to “put the phone down” improve the quality of bystander initiated dispatch-assisted CPR. Methods: In a randomized, double-blinded, controlled trial, subjects were randomized to a modified version of the Medical Priority Dispatch System® (MPDS) version 11.2 protocol or a simplified protocol, each with or without instruction to “put the phone down” during CPR. Data were recorded from a Laerdal® Resusci® Anne Skillreporter™ manikin. A simulated emergency medical dispatcher, contacted by cell phone, delivered standardized instructions. Primary outcome measures included chest compression rate, depth, and the proportion of compressions without error, with correct hand position, adequate depth, and total release. Time was measured in two distinct ways: time required for initiation of CPR and total amount of time hands were off the chest during CPR. Proportions were analyzed by Wilcoxon rank sum tests and time variables with ANOVA. All tests used a two-sided α-level of 0.05. Results: Two hundred and fifteen subjects were randomized—107 in the “put the phone down” instruction group and 108 in the group without “put the phone down” instructions. The groups were comparable across demographic and experiential variables. The additional instruction to “put the phone down” had no effect on the proportion of compressions administered without error, with the correct depth, and with the correct hand position. Likewise, “put the phone down” did not affect the average compression depth, the average compression rate, the total hands-off-chest time, or the time to initiate chest compressions. A statistically significant, yet trivial, effect was found in the proportion of compressions with total release of the chest wall. Conclusions: Instructions to “put the phone down” had no effect on the quality of bystander initiated dispatcher-assisted CPR in this trial. [Copyright &y& Elsevier]

Summary: Background: Out-of-hospital cardiac arrest (OHCA) accounts for 250.000–350.000 sudden cardiac deaths per year in the United States. The availability of automated external defibrillators (AEDs) promoted the implementation of public access defibrillation programs based on out-of-hospital early defibrillation by non-healthcare professionals. Aim of the study: To perform a systematic review and a meta-analysis of the pooled effect of studies comparing the outcome of pts receiving cardiopulmonary resuscitation plus AED therapy (CPR+AED) vs. cardiopulmonary resuscitation (CPR) alone, both delivered by non-healthcare professionals, for the treatment of OHCA. Methods: We performed a search of the relevant literature exploring major scientific databases, carrying out a hand search of key journals, analysing conference proceedings and abstracts and discussing the topic with other researchers. Two analyses were planned to assess the outcomes of interest (survival to hospital admission and survival to hospital discharge). Results: Three studies were selected for the meta-analysis. The first meta-analysis evidenced a RR of 1.22 (95% C.I.: 1.04–1.43) of surviving to hospital admission for people treated with CPR+AED as compared to CPR-only. The second meta-analysis showed a RR of 1.39 (95% C.I.: 1.06–1.83) of surviving to hospital discharge for people treated with CPR+AED as compared to CPR-only. Conclusions: The results of our meta-analysis demonstrate that programs based on CPR plus early defibrillation with AEDs by trained non-healthcare professionals offer a survival advantage over CPR-only in OHCA. The conclusions of our meta-analysis add to previous evidence in favour of developing public-health strategies based on AED use by trained layrescuers. [Copyright &y& Elsevier]

Summary: Purpose: Cerebral oxidative stress and metabolic dysfunction impede neurological recovery from cardiac arrest-resuscitation. Pyruvate, a potent antioxidant and energy-yielding fuel, has been shown to protect against oxidant- and ischemia-induced neuronal damage. This study tested whether acute pyruvate treatment during cardiopulmonary resuscitation can prevent neurological dysfunction and cerebral injury following cardiac arrest. Methods: Anesthetized, open-chest mongrel dogs underwent 5min cardiac arrest, 5min open-chest cardiac compression (OCCC), defibrillation and 3-day recovery. Pyruvate (n =9) or NaCl volume control (n =8) were given (0.125mmolkg−1 min−1 i.v.) throughout OCCC and the first 55min recovery. Sham dogs (n =6) underwent surgery and recovery without cardiac arrest-resuscitation. Results: Neurological deficit score (NDS), evaluated at 2-day recovery, was sharply increased in NaCl-treated dogs (10.3±3.5) versus shams (1.2±0.4), but pyruvate treatment mitigated neurological deficit (NDS=3.3±1.2; P <0.05 versus NaCl). Brain samples were taken for histological examination and evaluation of inflammation and cell death at 3-day recovery. Loss of pyramidal neurons in the hippocampal CA1 subregion was greater in the NaCl controls than in pyruvate-treated dogs (11.7±2.3% versus 4.3±1.2%; P <0.05). Cardiac arrest increased caspase-3 activity, matrix metalloproteinase activity, and DNA fragmentation in the CA1 subregion; pyruvate prevented caspase-3 activation and DNA fragmentation, and suppressed matrix metalloproteinase activity. Conclusion: Intravenous pyruvate therapy during cardiopulmonary resuscitation prevents initial oxidative stress and neuronal injury and enhances neurological recovery from cardiac arrest. [Copyright &y& Elsevier]

Summary: Background: Depending on the clinical setting, rescuers may provide CPR from a kneeling (if the patient is on the ground) or standing (if the patient is in a bed) position. The rescuer position may affect workload, and hence rate of fatigue and quality of CPR. Purpose: This study evaluates how three common rescuer positions affect the kinematics of CPR and the force of delivered compressions. Methods: Subjects were 18 health care providers experienced in CPR. Each participant performed CPR from three different positions: kneeling beside the Resusci® Anne manikin placed on the floor (F); standing beside the manikin placed on a Table 63cm in height (H), and standing beside the manikin placed on a Table 37cm in height (L). The compression to ventilation ratio was 15:2. CPR duration was 5min for each position, with a rest period of 50min in-between. The order of position was randomised. The manikin was equipped with a six-axial force load cell to collect 3D compression forces at a sampling rate of 1000Hz. An eight-camera Motion Analysis Digital System was adopted to collect 3D trajectory information. Data were compared using crossover-design analysis of variance (p <0.05 was regarded as statistically significant). Ratings of Perceived Exertion (RPE) were measured by modified Borg scale. Results: Significant differences were observed in the head, shoulder, lower trunk, hip and knee angles between the three methods. Lower trunk flexion angle (°) for H, L, and F were −14.52±1.13, −28.83±1.75, and 14.39±1.14, respectively. Hip flexion angle for H, L, and F were −16.21±3.30, −42.59±4.75, and −47.39±4.36, respectively. However, compression force (N) in H, L, and F were 455.8±17.6, 455.7±14.0, 461.5±13.5, respectively (p >0.05). Compression depths (mm) were: 43.5±3.4, 42.0±5.4, 44±5.2, respectively (p >0.05). Compression frequencies (times/min) were: 117.9±12.4, 116.6±13.4, 108.8±11.7, respectively (p >0.05). No differences were found between the three positions for RPE. Conclusions: In this study, while the kinematics of CPR differed significantly with varying rescuer position, these differences did not affect the compression force, depth and frequency as performed by experienced providers. [Copyright &y& Elsevier]

Summary: Background: Undetected malpositioned or dislodged ventilation tubes during cardiac arrest have fatal consequences, and no single method can detect the tube position reliably during such low-flow states. We wanted to test the ability of impedance changes as measured across the chest via the standard defibrillation pads to distinguish between oesophageal and tracheal ventilations in non-circulated patients. Materials and methods: After the end of futile resuscitation transthoracic impedance was measured with a prototype defibrillator, and ventilation variables were collected with a spirometer-capnography unit during tracheal ventilations and after repositioning of the tube; during oesophageal ventilations for paired comparisons. Results: We registered 123 oesophageal and 178 tracheal ventilations in nine patients. Transthoracic impedance changes associated with ventilations were always larger during tracheal than oesophageal ventilations (mean difference 1.3Ω (95% CI 1.0, 1.5), P <0.001), and all such changes above 1.2Ω were associated with tracheal ventilations, while changes below 0.4Ω always were associated with oesophageal ventilations. By subtracting 0.5Ω from the individual mean transthoracic change associated with tracheal ventilations, tube position was predicted with sensitivity 0.99 and specificity 0.97. Conclusion: Transthoracic impedance changes may be used to detect malpositioned and dislodged tubes also during situations without spontaneous circulation. Our predictive values must be retested in another population. [Copyright &y& Elsevier]

Summary: Aim: To highlight the main differences between the current editions of the Newborn Life Support (NLS; Resuscitation Council, UK) and the Neonatal Resuscitation Program (NRP; American Academy of Pediatrics and American Heart Association), and to analyse differences between the evidence underlying NLS and NRP. Material and methods: We undertook a detailed comparison of recommendations and references, based on the NLS and the NRP provider course manuals issued in 2006. Literature on neonatal resuscitation, published in 2005 and thereafter, was searched, focusing on controversies between NLS and NRP. Results: A multitude of important differences between NLS and NRP have been reaffirmed in their current editions, leading to conflicting messages regarding many aspects of resuscitation. An incongruent selection of evidence appears to be a major factor accounting for this divergence. Conclusion: To avoid confusion among health care providers and to support the credibility of both NLS and NRP, an intensified dialogue and a more congruent evidence base between NRP and NLS is required. Mutual recognition of equivalency appears unrealistic until substantial progress in this direction has been achieved. [Copyright &y& Elsevier]

Summary: Aim of the study: There is sufficient evidence that therapeutic hypothermia after non-traumatic cardiac arrest improves neurological outcome and reduces mortality. Many different invasive and non-invasive cooling devices are currently available. Our purpose was to show the efficacy, safety and feasibility using a non-invasive cooling device to control patient temperature within a range of 33–37°C. Materials and methods: A convenience sample of patients who have been resuscitated successfully from cardiac arrest and were intended for mild hypothermia therapy according to the guidelines and inclusion criteria were studied in a prospective observational case series at an emergency department of a tertiary care university hospital. The Medivance Arctic Sun System provides a new, non-invasive approach to reach a target temperature of 33°C quickly, to maintain the target temperature for 24h, and then to actively re-warm at 0.4°C/h to normothermia. Cooling was applied using the Arctic Sun in 27 patients. Data are presented as median and the interquartile range (25, 75%). Results: Median age was 58 (49.5, 70) years. Time from cooling start to target temperature was 137 (96, 168)min, cooling rate was 1.2°C/h (0.8, 1.5), stability of target temperature during hypothermia maintenance phase was satisfactory at 33.0°C (32.9, 33.1), and duration of re-warming was 428 (394, 452)min. Conclusion: Using the Arctic Sun System in post-resuscitation care medicine for cooling cardiac arrest survivors is feasible and has proven to be highly effective in lowering patients’ temperature rapidly without inducing skin irritations. [Copyright &y& Elsevier]

Summary: Introduction: The quality of cardiopulmonary resuscitation (CPR) plays a crucial role in saving lives from out-of-hospital cardiac arrest (OHCA). Previous studies have identified sub-optimal CPR quality in the prehospital settings, but the causes leading to such deficiencies were not fully elucidated. Objective: This prospective study was conducted to identify operator- and ambulance-related factors affecting CPR quality during ambulance transport; and to assess the effectiveness of mechanical CPR device in such environment. Materials and methods: A digital video-recording system was set up in two ambulances in Taipei City to study CPR practice for adult, non-traumatic OHCAs from January 2005 to March 2006. Enrolled patients received either manual CPR or CPR by a mechanical device (Thumper). Quality of CPR in terms of (1) adequacy of chest compressions, (2) instantaneous compression rates, and (3) unnecessary no-chest compression interval, was assessed by time-motion analysis of the videos. Results: A total of 20 ambulance resuscitations were included. Compared to the manual group (n =12), the Thumper group (n =8) had similar no-chest compression interval (33.40% versus 31.63%, P =0.16); significantly lower average chest compression rate (113.3±47.1min−1 versus 52.3±14.2min−1, P <0.05), average chest compression rate excluding no-chest compression interval (164.2±43.3min−1 versus 77.2±6.9min−1, P <0.05), average ventilation rate (16.1±4.9min−1 versus 11.7±3.5min−1, P <0.05); and longer no-chest compression interval before getting off the ambulance (5.7±9.9s versus 18.7±9.1s, P <0.05). The majority of the no-chest compression interval was considered operator-related; only 15.3% was caused by ambulance related factors. Conclusions: Many unnecessary no-chest compression intervals were identified during ambulance CPR, and most of this was operator, rather than ambulance related. Though a mechanical device could minimise the no-chest compression intervals after activation, it took considerable time to deploy in a system with short transport time. Human factors remained the most important cause of poor CPR quality. Ways to improve the CPR quality in the ambulance warrant further study. [Copyright &y& Elsevier]

Summary: Background: The majority of cardiac arrests occur in the home. The placement of AEDs in the homes of at-risk patients may save lives through early defibrillation. However, the impact of having an AED in the home on psychological outcomes and quality-of-life is unknown. Objective: The purpose of this research was to determine whether training in the use of and possessing an automated external defibrillator (AED) has an effect on a patient at risk''s quality of life. Methods: We investigated the psychological consequences of AED training and possession of such a device for patients who recently experienced an acute ischemic event. One hundred fifty eight patients and their family members were assigned at random to receive cardiopulmonary resuscitation (CPR) training (N =66) or AED/CPR training and possession of the device after training (N =92). We measured quality of life using the Short-Form (SF-36) survey and a 9-item survey we developed specifically for this study to measure differences in social activities and worries about being left alone. Participants answered these questions at enrollment, 2 weeks, 3 months, and 3 months after enrollment. Results: Patients in the AED group reported lower (worse) scores on most SF-36 subscales at all periods, particularly in those subscales relating to social functioning. The differences were most often small and probably not clinically meaningful. The social activities/worry scales also favored the CPR group at all periods, but with no significant differences. Conclusions: Physicians counselling patients about AEDs should be aware of the potential effects the device may have on a patient''s social functioning. [Copyright &y& Elsevier]

Summary: Background: CPR quality is an important determinant of cardiac arrest outcome. Recent investigations have demonstrated that quality of clinical CPR is variable and often not in compliance with international consensus guidelines. The 2005 update of these guidelines included new recommendations for the measurement of resuscitation and CPR performance and the institution of measures to improve resuscitation care. Common definitions and reporting templates need to be established for the variables of CPR quality. This will allow for meaningful comparisons between treatment groups in clinical trials as well as a common system for quality improvement and documentation of this improvement. Methods/results: In this report, we present the results from an international consensus working group to propose common definitions and criteria for reporting variables of CPR quality, based on the best available data for the importance of various CPR variables. The recommendations are discussed in light of the different purposes outlined above. [Copyright &y& Elsevier]

Summary: Objectives: To determine the characteristics of the geriatric patient population subjected to resuscitation attempts at a 1000-bed university hospital and to determine factors associated with mortality and outcome after in-hospital CPR. Methods: Retrospective chart review. The hospital records from all patients >75 years subjected to in-hospital resuscitation attempts during 2000–2001 were reviewed. Data regarding patient characteristics, mode of arrest and outcome details were extracted. Results: During the study period 151 resuscitation attempts were registered, and 53 (35%) of the patients were ≥75 years of age. The average age was 81 years; 29/53 (55%) patients were female. The admission diagnosis was “cardiac ischaemia” (angina pectoris, myocardial infarction) in 18/53 (34%) of the patients. PEA (pulseless electric activity) was the most common primary arrhythmia (17/53, 32%), and cardiac aetiology was the most common cause of arrest (41/53, 77%). The time of arrest was spread equally over the day. Most resuscitation attempts were performed at the general wards (28 patients, 53%). More then half-part of the patients died immediately (32/53, 60%); initially ROSC (return of spontaneous circulation) was established in 21/53 (40%) patients. A total of 9/53 (17%) patients were discharged home. ‘Do not attempt resuscitation’ (DNAR) orders or a statement that DNAR orders had been discussed with the patient was not documented in any of the patients resuscitated. Conclusion: Selected patients among the geriatric hospitalised patients may benefit a from a short resuscitation attempt. This includes especially those admitted for cardiac ischemia suffering a cardiac arrest with VT or VF as a primary arrhythmia or patients suffering a primary respiratory/hypoxic arrest. Patients who are unlikely to benefit from CPR should be identified on or during hospital admission and the possibility of DNAR orders should be discussed to avoid inappropriate treatment and potential patient suffering. There is a need for implementing routines for discussing the existence of advance-directives or DNAR orders upon admission. [Copyright &y& Elsevier]

Summary: Objective: Advanced life support (ALS) in a cardiac arrest is usually performed by a team consisting of three people. The medical team of a Helicopter Emergency Medical Service (HEMS) often consists of two rescuers only. Due to that reason an algorithm was developed to provide ALS with two people. During the initial phase the rescuer in the over-the-head position provides one man CPR while the second rescuer prepares all advanced measures. When all preparations are complete both rescuers are able to provide ALS. Material and methods: A computer controlled manikin (Ambu Mega Code Simulator System MCS®) with online documentation was used to test the entire medical staff during 10min of persistent VF. Results: The 20 teams were tested. Following data were recorded: no-flow-time 96.4±11s (16.1±1.8%), chest compression frequency 120.1±5.1min−1, ventilation frequency=9min−1, number of chest compressions per session 1013.7±45.9, depth of chest compressions 46.6±2.5mm, total number of chest compressions=20,274, total number of ventilations=1893. For ALS measures the following data were recorded: tracheal intubation (TI) was finished after 60.7±9.8s, duration of TI maneouver=15.7±4.4s, end of initial phase=188.9±26.3s, i.v. administration of adrenaline after 387.7±33.6s, i.v. administration of amiodarone after 507.9±36.9s and four shocks after: 138.0±15.9, 266.8±16.1, 398.0±20.1 and 526.8±23.6s. Conclusion: We proved the feasibility of the algorithm in a manikin setting. Further observations have to prove the algorithm in real CPR situations. [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: Objective: A head-to-head trial was conducted to compare laypersons’ long-term retention of life-saving psychomotor and cognitive skills learned in the traditional multi-hour training format for basic cardiopulmonary resuscitation and automated external defibrillator use to those learned in an abbreviated (30min) course. Methods: Laypersons were randomized to either: (1) the traditional multi-hour Heartsaver-Automated External Defibrillator ® (Heartsaver-AED ®) group; or (2) the 30-min course group (cardiopulmonary resuscitation, choking, and automated external defibrillator use). Immediately after training, and at 6 months, participants were provided identical individual testing scenarios. In addition to audio–video recordings, computerized recordings of compression rate/depth, ventilation rates, and related pauses were obtained and subsequently rated by blinded reviewers. Results: Performance following 30-min training was either equivalent or superior (p <0.007) to the multi-hour Heartsaver-Automated External Defibrillator training in all measurements, both immediately and 6 months after training. Although retention of certain skills deteriorated over the 6 months among a significant number of participants from both groups, 84% of the 30-min training group still was judged, overall, to perform cardiopulmonary resuscitation adequately. Moreover, 93% still were performing chest compressions adequately and 93% continued to apply the automated external defibrillator and deliver shocks correctly. Conclusions: Using innovative learning techniques, 30-min cardiopulmonary resuscitation and automated external defibrillator training is as effective as traditional multi-hour courses, even after 6 months. Thirty-minute courses should decrease labor intensity, demands on resources, and time commitments for cardiopulmonary resuscitation courses, thus facilitating more widespread and frequent retraining. [Copyright &y& Elsevier]

Summary: Background: A recently published study has shown that survival after out-of-hospital cardiac arrest (OHCA) in Göteborg is almost three times higher than in Stockholm. The aim of this study was to investigate whether in-hospital factors were associated with outcome in terms of survival. Methods: All patients suffering from OHCA in Stockholm and Göteborg between January 1, 2000 and June 30, 2002 were included. The two groups were compared with reference to patient characteristics, medical history, pre-hospital and hospital course (including in-hospital investigations and interventions) and mortality. All medical charts from patients admitted alive to the different hospitals were studied. Data from the Swedish National Register of Deaths regarding long-term survival were analysed. Pre-hospital data were collected from the Swedish Ambulance Cardiac Arrest Register. Results: In all, 1542 OHCA in Stockholm and 546 in Göteborg were registered during the 30-month study period. In Göteborg, 28% (153 patients) were admitted alive to the two major hospitals whereas in Stockholm 16% (253 patients) were admitted alive to the seven major hospitals (p <0.0001). On admission to the emergency rooms, a larger proportion of patients in Stockholm was unconscious (p =0.006), received assisted breathing (p =0.008) and ongoing CPR (p =0.0002). Patient demography, medical history, in-hospital investigations and interventions and in-hospital mortality (78% in Göteborg, 80% in Stockholm) did not differ between the two groups. Various pre-hospital time intervals were significantly longer in Stockholm than in Göteborg. Total survival to discharge after OHCA was 3.3% in Stockholm and 6.1% in Göteborg (p =0.01). Conclusion: An almost 2-fold difference in survival after OHCA between Stockholm and Göteborg appears to be associated with pre-hospital factors only (predominately in form of prolonged intervals in Stockholm), rather than with in-hospital factors or patient characteristics. [Copyright &y& Elsevier]

Summary: Objectives: To analyse how rescuers tolerate the effort derived of giving uninterrupted chest compressions during 2min. Materials and methods: Twenty-three healthy volunteers, nurses and doctors of the Intensive Care Unit (ICU), members of the hospital cardiac arrest team, were enrolled in the study. Using a training manikin, participants were asked to perform chest compressions during 2min at a rate of 100min−1. The oxygen saturation and cardiac rate of the subjects were monitored using pulse oximetry before and after one and 2min performing chest compressions. The percentage of the maximal heart rate of the rescuer over the theoretical maximum allowed in a conventional stress test was calculated, taking into account age and body mass index (BMI) of the subjects. Fatigue was measured using a visual analogical scale (VAS). Results: The means (±S.D.) of chest compressions in the first and second minutes were 103±12, and 104±11, respectively. The mean percent of the maximum heart rate observed was 61±8%. None of the subjects had difficulties to complete the test. All subjects recovered their basal values in less than 2min, and the mean value recorded in the VAS was 3±2. Conclusions: The practice of uninterrupted chest compressions during 2min by the same rescuer is well tolerated by health professionals trained in cardiopulmonary resuscitation (CPR). [Copyright &y& Elsevier]

Summary: Purpose: To determine the performance of two person CPR on an instrumented manikin by registered nurses using conventional bag valve mask (BVM) ventilation or the Impact Model 730 automatic transport ventilator (Impact 730, Impact Instrumentation, Inc., West Caldwell, NJ) in CPR mode using a face mask. Design: Randomized crossover quasi-experimental. Setting: Laboratory simulation. Subjects: Twenty-eight registered nurses trained in performing adult cardiopulmonary resuscitation (CPR). Interventions: Basic Life Support was provided by subjects using a conventional bag valve mask (BVM) ventilation or mask ventilation with an automatic transport ventilator, the Impact 730, which incorporates a metronome to facilitate chest compression timing. Subjects alternated performing 4min of CPR using the BVM or Impact 730 to deliver breaths with a mask while the other subject performed compressions. Measurements and main results: Flow, volume and pressure were measured using a pneumotachograph and pressure transducer, and ease of use was measured using a 10cm visual analogue scale. There was no statistical or clinical difference between the actual and recommended tidal lung volume (mean±S.D.) delivered by the Impact 730 (−120.4±91.5ml) versus the BVM (−119.8±187.3±ml). Ventilation with the BVM resulted in more (137.7±143.9ml) air per breath passing through the simulated lower esophageal sphincter compared to the Impact 730 (14.0±16.8ml, p <0.05). The reduced mask leak per breath with the Impact 730 (176.1±98.3ml) compared to the BVM (367.6±337.7ml, p <0.05) is likely to have resulted from the subject being able to manage the mask with two rather than one hand and is reflected in the higher ease of use score on a 10cm visual analogue scale with the Impact 730 (8.06±1.35cm) versus the BVM (6.46±2.46cm, p <0.05). Subjects tended to deliver slightly more compressions and breaths when using the BVM. Conclusion: Compared to the BVM, the Impact 730 is as effective, easier to use and limits the amount of gas entering the stomach when used during adult CPR in a simulated setting. [Copyright &y& Elsevier]

Background: The time to skill deterioration between primary training/retraining and further retraining in cardiopulmonary resuscitation (CPR) and automated external defibrillation (AED) for lay-persons is unclear. The Public Access Defibrillation (PAD) trial was a multi-center randomized controlled trial evaluating survival after CPR-only versus CPR+AED delivered by onsite non-medical volunteer responders in out-of-hospital cardiac arrest.Aims: This sub-study evaluated the relationship of time between primary training/retraining and further retraining on volunteer performance during pretest AED and CPR skill evaluation.Methods: Volunteers at 1260 facilities in 24 North American regions underwent training/retraining according to facility randomization, which included an initial session and a refresher session at approximately 6 months. Before the next retraining, a CPR and AED skill test was completed for 2729 volunteers. Primary outcome for the study was assessment of global competence of CPR or AED performance (adequate versus not adequate) using chi(2)-test for trends by time interval (3, 6, 9, and 12 months). Confirmatory (GEE) logistic regression analysis, adjusted for site and potential confounders was done.Results: The proportion of volunteers judged to be competent did not diminish by interval (3, 6, 9, and 12 months) for either CPR or AED skills. After adjusting for site and potential confounders, longer intervals to further retraining was associated with a slightly lower likelihood of performing adequate CPR but not with AED scores.Conclusions: After primary training/retraining, the CPR skills of targeted lay responders deteriorate nominally but 80% remain competent up to 1 year. AED skills do not deteriorate significantly and 90% of volunteers remain competent up to 1 year. [ABSTRACT FROM AUTHOR]

Summary: Background: Rhythm analysis with current semi-automatic external defibrillators (AEDs) requires mandatory interruptions of chest compressions that may compromise the outcome after cardiopulmonary resuscitation (CPR). We hypothesised that interruptions would be shorter when the defibrillator was operated in manual mode by trained and certified ambulance personnel. Materials and methods: Sixteen pairs of ambulance personnel operated the defibrillator (Lifepak®12) in both semi-automatic (AED) and manual (MED) mode in a randomised, cross-over manikin CPR study, following the ERC 2000 Guidelines. Results: Median time from last chest compression to shock delivery (with interquartile range) was 17s (13, 18) versus 11s (6, 15) (mean difference (95% CI) 6s (2, 10), p =0.004). Similarly, median time from shock delivery to resumed chest compressions was 25s (22, 26) versus 8s (7, 12) (median difference 13s, p =0.001) in the AED and MED groups, respectively. While sensitivity for identifying ventricular fibrillation (VF) in both modes and specificity in the AED mode were 100%, specificity was 89% in manual mode. Thus, some unwarranted shocks resulting in hands-off time (time without chest compressions) were given in manual mode. However, mean hands-off-ratio (time without chest compressions divided by total resuscitation time) was still lower, 0.2s (0.1, 0.3) versus 0.3s (0.28, 0.32) in manual mode, mean difference 0.10s (0.05, 0.15), p =0.001. Conclusion: Paramedics performed CPR with less hands-off time before and after shocks on a manikin with manual compared to semi-automatic defibrillation following the 2000 Guidelines. However, 12% of the shocks given manually were inappropriate. [Copyright &y& Elsevier]

Summary: “Bystanders” or lay persons are typically the first caregivers to attend to a victim of out-of-hospital cardiopulmonary arrest. Astronaut crew medical officers (CMO) play a similar role to bystanders aboard the International Space Station (ISS). Studies have demonstrated the importance of bystander cardiopulmonary resuscitation (BCPR) for patient survival before the arrival of emergency medical care. Recent apprehension from bystanders about the threat of contracting communicable diseases during BCPR, however, has led to the consideration of other ventilation systems such as the bag-valve mask (BVM) and automatic transport ventilators (ATV). BVM use is called for during CPR aboard the ISS. This study evaluated the ventilation and compression performance of 40 basic CPR-trained bystanders using either a BVM (adult-sized self-inflating bag with face mask) or an ATV (Model 730 ventilator (M730), Impact Instrumentation, Inc., West Caldwell, NJ). Each two-bystander team gave BCPR to a simulated cardiopulmonary arrest victim using the 2-breath/15-compression cycle for 4min and then switched roles for another 4-min interval. Compared to BVM use, the M730 led to significantly (p <0.05) lower number of breaths, smaller tidal volumes, airway flows, airway pressures, volume of gas entering the stomach per breath and chest compressions for the 4-min period. The M730 also enabled a bystander to meet the recommendation of 4-breath and compression cycles per minute as per Guidelines 2000. Lastly, ease-of-use scores were significantly higher for the M730 compared to the BVM. Overall, the data suggest that the M730 improves the quality of performance for a bystander performing BCPR. [Copyright &y& Elsevier]

Summary: Objective: No single drug improves survival after cardiac arrest, despite success in animal studies. We sought to determine the duration of circulatory arrest after which maximal drug treatment and a rescue shock would fail to achieve return of spontaneous circulation (ROSC). Design/subjects: Retrospective analysis of 271 swine (20–30kg) resuscitation attempts during ventricular fibrillation. Protocols were divided into five categories: immediate countershock, cardiopulmonary resuscitation (CPR) with standard-dose drugs, CPR alone, CPR and high-dose epinephrine (CPR+HDE) (0.1mg/kg), and CPR with a drug cocktail (CPR+DC) of propanolol (1mg), epinephrine (adrenaline) (0.1mg/kg) and vasopressin (40IU). Time to first CPR, time to first drug administration, time to first shock, and protocol were examined as predictors of ROSC using logistic regression with Hosmer–Lemeshow test of fit. Probability of ROSC was calculated from logistic curves. Main results: ROSC occurred in 119 of the 271 swine (44%). Time to first drug and the CPR+DC group were predictors of ROSC. Time to first CPR, the CPR+DC group, and the CPR+HDE group were also predictors of ROSC. Time to first rescue shock, the CPR+DC group, and the CPR+HDE groups were predictors of ROSC. In the CPR+DC group, 50% ROSC occurred at a first CPR time of 13.4min, first drug time of 14.1min and first rescue shock time of 17.5min. Conclusions: Pre-shock delivery of CPR+DC increases the likelihood of ROSC, and reaches 50% with a time of drug delivery of 14.1min. ROSC rates of 50% may be achievable using an optimized resuscitation in experimental CPR. [Copyright &y& Elsevier]

Summary: Introduction: Current Advanced Medical Priority Dispatch System (AMPDS) V.11.1 telephone instructions are limited in their ability to produce correctly performed basic life support. The current telephone instructions were modified in an attempt to improve areas of poor CPR performance. Methods: Fifty subjects performed CPR on an instrumented adult manikin by following instructions modified from AMPDS V.11.1 instructions. Instructions were given by telephone from a different room. Results: No improvements were seen with opening the airway or delivering rescue breaths. The rate of chest compression improved from 52 to 81min−1 (P =0.004), although the depth of chest compression fell to 2.0cm compared with 3.2cm documented with the original AMPDS instructions (P =0.004). Instructions to put the telephone down while performing CPR improved all aspects of CPR. Discussion: The effective delivery of telephone-directed CPR to untrained bystanders is a complex process. Changing verbal instructions to improve the quality of CPR is not easy. Further work is urgently needed to strengthen this important link in the chain of survival. [Copyright &y& Elsevier]

Summary: An intrathoracic pressure regulator (ITPR) is a device that can be added to the external end of a tracheal tube to create controlled negative airway pressure between positive pressure ventilations. The resulting downward bias of the airway pressure baseline promotes increased venous return and enhanced circulation during CPR and also during hypovolemic shock. In the present study, we exercised a mathematical model of the human cardiopulmonary system, including airways, lungs, a four chambered heart, great vessels, peripheral vascular beds, and the biomechanics of chest compression and recoil, to determine the relationship between systemic perfusion pressure during CPR and the value of baseline negative airway pressure in an ITPR. Perfusion pressure increases approximately 50% as baseline airway pressure falls from zero to −10cm H2O. Thereafter perfusion pressure plateaus. Negative bias pressures exceeding −10cm H2O are not needed in ITPR-CPR. [Copyright &y& Elsevier]

Summary: Background: Complete chest wall recoil improves hemodynamics during CPR by generating relatively negative intrathoracic pressure, which draws venous blood back to the heart, providing cardiac preload prior to the next chest compression. Objective: This study was designed to assess the quality of CPR delivered by trained laypersons and to determine if a change in CPR technique or hand position would improve complete chest wall recoil, while maintaining adequate duty cycle, compression depth, and proper hand position placement. Standard manual CPR and three alternative manual CPR approaches were assessed. Methods: This randomized prospective trial was performed on an electronic test manikin. Thirty laypersons (mean age of 40.6 years (range 28–55)), who were trained in CPR within the last 24 months, signed an informed consent and participated in the trial. Subjects performed 3min of CPR on a Laerdal Skill Reporter™ CPR manikin using the Standard Hand Position followed by 3min of CPR (in random order) using three alternative CPR techniques: (1) Two-Finger Fulcrum Technique – lifting the heel of the hand slightly but completely off the chest during the decompression phase of CPR using the thumb and little finger as a fulcrum; (2) Five-Finger Fulcrum Technique – lifting the heel of the hand slightly but completely off the chest during the decompression phase of CPR using all five fingers as a fulcrum; (3) Hands-Off Technique – lifting the heel and all fingers of the hand slightly but completely off the chest during the decompression phase of CPR. The participants did not know the purpose of the study prior to, or during this investigation. Results: Adequate compression depth was poor for all hand positions tested and ranged only from 18.6 to 35.7% of all compressions. When compared with the Standard Hand Position, the Hands-Off Technique decreased the mean compression duty cycle from 39.0±1.0 to 33.5±1.0%, (P<0.0001) but achieved the highest rate of complete chest wall recoil (92.5% versus 24.1%, P <0.0001) and was 46.3 times more likely to provide complete chest wall recoil (OR: 46.3; CI: 16.4–130.3). There were no significant differences in accuracy of hand placement, adequate depth of compression, or perceived discomfort with its use compared with the Standard Hand Position. Conclusions: The Hands-Off Technique decreased compression duty cycle but was 46.3 times more likely to provide complete chest wall recoil (OR: 46.3; CI: 16.4–130.3) compared to the Standard Hand Position without differences in accuracy of hand placement, adequate depth of compression, or perceived discomfort with its use. All forms of manual CPR tested (including the Standard Hand Position) in trained laypersons produced an inadequate depth of compression for two-thirds of the time. These data support development and testing of more effective layperson CPR training programmes and more effective means to deliver manual as well as mechanical CPR. [Copyright &y& Elsevier]

Summary: A non-linear mathematical model of the oesophagus was developed to study the effects of non-invasive ventilation variables on the severity of gastric inflation. The model was based on the non-linear physical characteristics of biological tissue. The model simulated oesophageal mechanical function during non-invasive ventilation in cardiac arrest (2:30 ventilations/chest compressions cycles) and respiratory arrest (1:5ventilations/s) as recommended by the European Resuscitation Council (ERC) in its 2005 guidelines for adult basic and advanced life support. Model predictions establish a strong correlation between the expiratory time and the occurrence of gastric inflation. For cardiac arrest, when using ventilation pressure lower than 12cmH2O, expiratory time between consequent ventilations and time until the occurrence of gastric inflation were linearly dependant (r =0.98). This linear correlation changed abruptly when airway pressure exceeded the threshold pressure of 12cmH2O, indicating that air had entered the stomach during the first ventilation. The interval at which the pressure at the distal section of the oesophagus was above the lower oesophageal sphincter (LES) opening pressure was significantly prolonged in the model of cardiac arrest (approximately 5.5s compared to 3s in respiratory arrest), thus allowing a greater amount of air to enter the stomach at relatively low airway pressures. During cardiac arrest, the mean pressure at the distal section of the oesophagus and the amplitude of air backflow were higher compared to the mean pressure and amplitude during respiratory arrest. This is also due to the shorter expiratory intervals in the 2:30 ventilations/chest compressions technique. The model indicates that the time required for the air trapped in the oesophagus to completely deflate is approximately 2s. This may be longer than the expiratory time recommended by the 2005 guidelines. Model predictions support the 2005 guidelines regarding the decrease in the tidal volume and in the inspiratory pressure in an effort to minimise gastric inflation. [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: Objective: Witnessed collapse and bystander CPR are the variables most frequently associated with good outcome from out-of-hospital cardiac arrest (OOHCA). The reliability of abstracting witnessed collapse and bystander CPR from prehospital Emergency Medical Services (EMS) patient care records (PCRs) is not known. We sought to determine the inter-rater reliability for different methods of ascertaining and defining witnessed collapse and performance of bystander CPR. Methods: A sample of 100 PCRs for patients with OOHCA was selected at random from a pool of 325 PCRs between May 2003 and January 2005. Paramedics used a drop down menu to indicate witnessed collapse and bystander CPR, and completed a narrative description of the event. An on-scene EMS physician also completed a data sheet. The PCR was examined by two separate evaluators to determine the presence of witnessed collapse and bystander CPR. A consensus was reached by three other reviewers using all available data sources. Inter-rater agreement was quantified using the unweighted kappa statistic. Results: For witnessed collapse, there is substantial agreement between the following: individual evaluators (kappa=0.76, S.D.=0.07), individual evaluators and consensus group (kappa=0.61, S.D.=0.07 and 0.66, S.D.=0.07), and physician and consensus group (kappa=0.68, S.D.=0.08). Agreement between individual evaluators and the physician was fair to moderate (kappa=0.38, S.D.=0.07 and 0.44, S.D.=0.07). Agreement between individual evaluators, physician, consensus group and the PCR drop down menu was fair to moderate (kappa range 0.33, S.D.=0.09 to 0.54, S.D.=0.09). For bystander CPR, there is substantial agreement between the individual evaluators and the consensus group (kappa=0.64, S.D.=0.07 and 0.63, S.D.=0.06) and between the physician and the consensus group (kappa=0.61, S.D.=0.08). Agreement between the two individual evaluators is moderate (kappa=0.59, S.D.=0.07). Agreement between the physician and individual evaluators is fair (kappa=0.36, S.D.=0.07 and 0.38, S.D.=0.07). The PCR drop down menu had moderate to substantial agreement with the individual evaluators, physician, and consensus group (kappa range 0.50, S.D.=0.09 to 0.75, S.D.=0.09). Conclusions: Determination of witnessed collapse and bystander CPR during OOHCA may be less reliable than previously thought, and differences between methods of rating could influence study results. [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]