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The article presents a study which aims to evaluate the retention of basic life support (BLS) knowledge of third year nursing and fourth year chiropractic students at Royal Melbourne Institute of Technology (RMIT) in Victoria. Study participants include 87 third year undergraduate nursing and 43 fourth year undergraduate chiropractic students. It revealed that chiropractic students have some difficulties in identifying correct compression rate compared to the nursing group.

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

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

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

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

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

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

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

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

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

Abstract: Background: Guidelines for the management of cardiac arrest during pregnancy exist but they are based on little research. The study hypothesis was that experienced medical clinicians who specialise in obstetric care would not follow current International Liaison Committee on Resuscitation/American Heart Association recommendations in this situation. Methods: Following waiver of informed consent by the institutional review board, an anonymous structured scenario questionnaire survey was conducted among relevant hospital clinicians. Demographic details included field of expertise and resuscitation experience. A single case vignette of maternal cardiac arrest was presented, followed by nine questions to examine knowledge of existing recommendations for maternal cardiopulmonary resuscitation. Statistical analyses were performed using SPSS version 12 software (SPSS Inc, Chicago, IL). Results: The overall response rate was 67% (30/45 questionnaires). Specialist obstetricians, midwives and anaesthetists from 17 hospitals participated. Forty-three percent (n=13) claimed broad experience, 50% (n=15) claimed some experience and 6.7% (n=2) claimed no experience in adult resuscitation. Participants were divided in their opinions regarding every choice of action: positioning, need to administer cricoid pressure during mask ventilation, timing of intubation, location of external chest compression, location of paddle placement for delivery of shock during ventricular fibrillation, the timing of defibrillation versus fetal delivery, medication doses and the need to rupture the membranes at an early phase of the resuscitation. Conclusion: Specialist clinicians who treat pregnant women in hospital on a daily basis possess a limited knowledge of the recommendations for treating maternal cardiac arrest. [Copyright &y& Elsevier]

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

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

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

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

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

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

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

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

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

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

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

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

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

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]

Objective: To evaluate immediate life support (ILS) training in a primary care setting. Methods: A 12 month pre/post-quasi-experimental and qualitative evaluation of ILS training across the counties of Devon and Cornwall (UK). Data were collected via feedback forms, pre/post course knowledge and skills tests and by focus group interviews with key stakeholders. Results: One hundred and seventy-three professionals from 10 courses took part in the evaluation with a response rate of 93%. Feedback on the course was overwhelmingly positive. A significant improvement in both skills (p < or = 0.001) and knowledge (p < or = 0.001) was shown. However, a proportion of participants had a decline in knowledge by the end of the course. Those attending ILS had a significantly higher knowledge score at the start of the course (p = 0.002) than a group attending a BLS course, indicating that the preparatory course manual had been beneficial. Knowledge did not decline significantly by 6 months but skills did (p = 0.02), but remained higher than pre-course levels (p < or = 0.001). Knowledge (p = 0.008) and skill (p < or = 0.002) retention following the ILS course was significantly higher than in the BLS course sub-group, indicating the added value of ILS. The focus groups raised a number of themes relating to release of staff; funding issues; and the observed and reported effects of assessment inequity mainly relating to 'failure to fail' and 'dove and hawk' approaches. Conclusion: The course leads to a significant increase in skills and knowledge with good knowledge retention. Skill decline is significant which raises questions about the practice of practitioners who are not updated regularly. Issues of funding, staff resources and the assessment ethics and strategy need to be addressed. [ABSTRACT FROM AUTHOR]

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]

Summary: Background: Scientific evidence is scarce in relation to the effectiveness of different methods of teaching automated external defibrillator (AED) use to laypeople. A reference course is needed in order to test new courses or methods against a comparative standard. Objective: To propose a reference AED 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 were sent a questionnaire about the AED provider courses run by them or under their auspices. Results: Sixteen national resuscitation councils responded to the enquiry. Apart from the individual course timetables, there was remarkable consistency amongst the European countries as regards organisation, structure, content and methods. Conclusions: A reference AED provider course for laypeople, based on a synthesis of existing European courses, is suggested as a tool for research. Prior completion of a basic life support provider course is mandatory. Course duration is 2h 45min (excluding breaks), with 1h 40min practice time for the participants, 25min for theory, 20min for practical demonstrations by the instructor and 20min for introduction, discussion and closure. A manual is distributed at the start of the course. The ratio of instructors to participants is one to six. Lectures are interactive between the instructor and the class. AED use is practised in groups of six participants. Participants prove their competency by means of a formal test that simulates a cardiac arrest scenario. Using this course as a comparator during research into the methodology of AED teaching would provide a reference against which other courses could be tested. [Copyright &y& Elsevier]

Summary: Study objective: This study correlated the delay in initiation of bystander cardiopulmonary resuscitation (ByCPR), basic (BLS) or advanced cardiac (ACLS) life support, and transport time (TT) to survival from prehospital cardiac arrest. This was a secondary endpoint in a study primarily evaluating the effect of bicarbonate on survival. Design: Prospective multicenter trial. Setting: Patients treated by urban, suburban, and rural emergency medical services (EMS) services. Patients: Eight hundred and seventy-four prehospital cardiac arrest patients. Interventions: This group underwent conventional ACLS intervention followed by empiric early administration of sodium bicarbonate noting resuscitation times. Survival was measured as the presence of vital signs on emergency department (ED) arrival. Data analysis utilized Student''s t-test and logistic regression (p <0.05). Results: Survival was improved with decreased time to BLS (5.52min versus 6.81min, p =0.047) and ACLS (7.29min versus 9.49min, p =0.002) intervention, as well as difference in time to return of spontaneous circulation (ROSC). The upper limit time interval after which no patient survived was 30min for ACLS time, and 90min for transport time. There was no overall difference in survival except at longer arrest times when considering the primary study intervention bicarbonate administration. Conclusion: Delay to the initiation of BLS and ACLS intervention influenced outcome from prehospital cardiac arrest negatively. There were no survivors after prolonged delay in initiation of ACLS of 30min or greater or total resuscitation and transport time of 90min. This result was not influenced by giving bicarbonate, the primary study intervention, except at longer arrest times. [Copyright &y& Elsevier]

Summary: Public access defibrillation (PAD) is a promising strategy to fight sudden cardiac death. The Austrian Red Cross provided automated external defibrillators (AEDs) and basic life support (BLS) training as an “all inclusive package” combined with on site consultation and maintenance with annual retraining as a part of a nationwide PAD programme. A multi media campaign was started to promote the package and to increase awareness about sudden cardiac death. Data about the campaign, its recognition by the public in Austria and the number of packages were recorded. Sixty-eight percent of the Austrian public above the age of 15 years were able to recall the multi media campaign. Comparing the periods before and after the campaign, the number of website hits climbed significantly from 2931 hits/month (1866–6168) to 4812 hits/month (3432–13,434) (p =0.0276). The number of AED services implemented before the campaign increased significantly (p =0.0026) in the time after the campaign. Therefore, we conclude that a multi media campaign is useful to stimulate public discussion and it encourages companies to buy “all inclusive packages” containing AEDs, BLS training, on site consultation and maintenance. These measures represent a possible first step in introducing PAD but it seems that they have to be continued on a constant basis. [Copyright &y& Elsevier]

Summary: Even after training, the ability to perform effective cardiac compressions has been found to be poor and to decrease rapidly. We assessed this ability with and without a non-invasive feedback device, the CPREzy™, during a 270s CPR session in an unannounced, single-blinded manikin study using 224 hospital employees and staff chosen at random and using a non-cross over design. The two groups self-assessed their knowledge and skills as adequate. However, the control group (N =111) had significantly more difficulty in delivering chest compressions deeper than 4cm (25 versus 1 candidate in the CPREzy group), P =0.0001. The control group compressed ineffectively in 36% (±41%) of all compressions as opposed to 6±13% in the CPREzy™ group (N =112, P =0.0001). If compressions were effective initially, the time until >50% of compressions were less than 4cm deep was 75±81s in the control group versus 194±87s in the CPREzy™ group (P =0.0001 [−180 to −57.5]). After a few seconds of training in its use, our candidates used the CPREzy™ effectively. Against the background knowledge that estimation of compression depth by the rescuer or other team members is difficult, and that performing effective compressions is the cornerstone of any resuscitation attempt, our data suggests that a feedback device such as the CPREzy™ should be used consistently during resuscitation. [Copyright &y& Elsevier]

Summary: Introduction: Guideline-directed therapy during the first minutes of resuscitation may be life saving. This study assessed the performance of American Heart Association (AHA) guidelines by trained departmental staff in the period between discovery of collapse and emergency team arrival. Methods: Over a period of 24 months, departmental performance prior to the arrival of the emergency team (median 180s) was assessed by debriefings conducted within 24h of each event in a 740-bed tertiary hospital with a dedicated certified resuscitation team. Outcome measures were failure to meet AHA treatment recommendations (primary) and return of spontaneous circulation (ROSC)/survival to hospital discharge (secondary). Results: Two hundred and forty four events were included (216 patients). Mean age was 69±17 years; 45% were women. The underlying causes of collapse were mainly cardiac (39%) or respiratory (32%). Residents conducted most of the resuscitations (69%) prior to the arrival of the emergency team. Basic diagnostic measures such as assessments of pulse and rhythm were not performed in 19 and 33% of events. Therapeutic measures such as positive pressure ventilation, chest compressions and defibrillation were not provided according to the guidelines in 17, 12 and 44% of the events. ROSC occurred in 62% of events; 54% of VF/VT, 30% of asystole, 22% of PEA and 76% of bradyarrhythmias/severe bradycardias. Survival to hospital discharge was 37% overall and 41% for patients found in VF/VT (n =33). Conclusions: Trained departmental staff performed poorly in the moments between patient discovery and arrival of the emergency team. Since patient outcomes were comparable to those described in the literature, poor resuscitation performance may be commonplace in hospitals where ward personnel are expected to deliver advanced life support prior to arrival of the emergency team. [Copyright &y& Elsevier]

Summary: Objective: Multiple procedures performed in parallel may cause each procedure to be performed less effectively than if performed in isolation. BLS performed by prehospital providers potentially includes artificial ventilations, chest compressions, and application of an automated external defibrillator (AED). This study examines the effectiveness of artificial ventilation and chest compressions both with and without an AED. Methods: Thirty-six prehospital providers participated in a prospective observational study. Tested in pairs (n =18), subjects randomly completed three, 6-min scenarios [apneic patient with a pulse (VENT), a pulseless patient (CPR), and a pulseless patient with an AED available (CPR+AED)]. A full-torso manikin capable of generating a carotid pulse was connected to a computer to record number of ventilations, tidal volume, flow rate, number of compressions, and compression depth. Data were analyzed by t-test, ANOVA, and Mann–Whitney U-test. Results: Artificial ventilation performed in isolation provided more correct ventilations than during CPR or CPR+AED (25.7%, 14.2%, 13.7%, p =0.02). Fewer ventilations were delivered during CPR and CPR+AED (p =0.03). More compressions were delivered with CPR alone vs. CPR+AED (51.9, 35.7min−1, p =0.00). More correct compressions were delivered during CPR alone vs. CPR+AED (p =0.05). Conclusions: Both the quality and quantity of BLS decreases as the number of procedures performed simultaneously increases. Further decrements might occur when ALS skills enter into resuscitation. These results suggest a need to automate and/or prompt the performance of BLS to optimize resuscitation. [Copyright &y& Elsevier]

Background: In 2003 severe acute respiratory syndrome (SARS) affected 1,755 people in Hong Kong, including 386 health care professionals, some of whom were infected during resuscitation attempts of affected patients. This study seeks to explore whether this epidemic has altered the willingness of Hong Kong medical students to perform basic life support and mouth-to-mouth ventilation during an out-of-hospital cardiac arrest.Methods: A questionnaire was used to survey Year 4 medical students at the end of their undergraduate anaesthesia attachment, during which basic life support (BLS) skills were taught. The survey was conducted during July and August 2003, approximately two months after Hong Kong was removed from the World Health Organisation SARS Infected Areas list, and was designed to examine student confidence in BLS skills, their perceptions of the risks associated with performing BLS and their willingness to perform BLS in varying situations.Results: The response rate was over 60% (35 from a possible 54). Students were positive regarding the adequacy of their BLS training. They were concerned about disease transmission during resuscitation but were less positive regarding whether the risks had increased due to SARS. In all situations they were significantly more likely to perform mouth-to-mouth ventilation for a family member compared with a stranger (p < 0.001) and to withhold mouth-to-mouth ventilation if either vomit or blood were present in the victim's mouth.Conclusions: Hong Kong medical students feel able to perform BLS if required. They are concerned about the risk of disease transmission, including SARS, during resuscitation, but would be more likely to withhold mouth-to-mouth resuscitation in the presence of vomit or blood than due to a fear of contracting SARS. [ABSTRACT FROM AUTHOR]

Abstract: Since June 2002, revised regulations in Germany allow medical faculties to implement new curricular concepts. The medical faculty of the Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, Germany, decided to start a major reform experiment in winter 2003, focussing on an interdisciplinary integration of organs and organ systems such as the cardiovascular or respiratory system. Furthermore, students will have contact with patients at an early stage of their studies. Thus, re-organisation of course contents should lead to a chance to improve practical experience. With the public having the right to expect that physicians and all physicians in training possess a basic knowledge of emergency medical care and the necessary skills to manage acute problems, it was decided to start the first year of the Medical Reform Curriculum Aachen with 3 weeks interdisciplinary introduction into emergency medical care. The task consisted of defining interdisciplinary core objectives and the need to implement teaching and learning principles necessary for further education. Due to this, the content of this course should have practical relevance for the students concerning their practical experiences in the future. The result is an introductory course in emergency medical care in the first semester, coordinated with the lectures. Besides skill training on basics of emergency medical care (basic life support (BLS), early defibrillation), practical training in other lifesaving techniques (e.g., immobilisation skills) and basic principles of daily clinical care are included. In addition, personal safety and a standard algorithm for assessing the patient are covered by problem-based learning sessions. The course evaluation data clearly showed acceptance of the new approach and enhances possibilities of extending implementation of relevant topics concerning emergency medical care within the Medical Reform Curriculum Aachen. [Copyright &y& Elsevier]

Abstract: The “Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – International Consensus on Science” recommend a tidal ventilation volume of 10ml/kg body-weight without the use of supplemental oxygen during two-rescuer adult cardiopulmonary resuscitation (CPR). This relates to a ventilation volume of about 6.4l/min. Additionally, the first aid provider ventilating the victim will breathe for him/herself during the external chest compression period adding another 3.2l/min of ventilation. Finally, a deep breath is recommended before each ventilation to increase the end-expiratory oxygen concentration of the air exhaled. To investigate the effects of these recommendations, 20 healthy volunteers were asked to perform two-rescuer CPR in a lung model connected to a BLS-manikin. End-tidal carbon dioxide, oxygen saturation, and heart rate were recorded continuously. Capillary blood gas samples were collected and non-invasive blood pressure was recorded prior to the start of external chest compressions and immediately after the end of each measurment period. Furthermore, hyperventilation related symptoms reported by the volunteers were also recorded. The data reveal a significant decrease in capillary and end-tidal carbon dioxide pressure in the volunteers (P &#60;0.001). Additionally, in 75% of test persons multiple hyperventilation associated symptoms occurred. Ventilation during two-rescuer CPR performed according to the Guidelines 2000 may cause injury to the health of first aid providers. To minimize hyperventilation, both rescuers should exchange their positions at intervals of 3–5min. These data challenge the recommendation to take a deep breath prior to each ventilation. [Copyright &y& Elsevier]

Abstract: Objective:: During basic life support (BLS) by a two-rescuer-team early defibrillation and ALS procedures should be performed without interruptions of the BLS-ventilation/compression sequence. The objective of this study was to determine the impact of a ventilation/compression ratio of 5:50 versus 2:15 on the time intervals “Start BLS to first shock” and “Start BLS to intubation”. Methods:: Using a random cross over design 40 experienced paramedics performed a standard BLS/ALS-algorithm according to ILCOR guidelines in a manikin model with ventricular fibrillation (resusci skillreporter anne, Laerdal®, Norway) performing both the 2:15 and the 5:50 ventilation/compression ratio. BLS was started with bag/valve/mask ventilation, a semi-automatic defibrillator (corpuls 08/16S) was connected with the manikin, ECG-analysis and three shocks were performed and the tracheal intubation was prepared. Ventilation/compression sequence was only interrupted during ECG-analysis and defibrillation. Expiratory volumes and number of compressions were measured. Variables were compared using paired Students t-test. In addition paramedics were interviewed about work-flow and emotional stress during the tests. Results:: The time interval “Start BLS to first shock” was 78s (2:15-group) versus 63s (5:50-group), p<0.0001, the time interval “Start BLS to intubation” was 183s (2:15-group) versus 150s (5:50-group), p<0.0001, mean ventilation volumes per minute were 4490ml (2:15-group) versus 4370ml (5:50-group), p>0.1, mean number of compressions were 65min-1. (2:15-group) versus 68min-1 (5:50-group), p>0.1. The work-flow and emotional stress was appraised by the paramedics to be significantly superior in the 5:50 ratio (p<0.0001). Conclusions:: The ventilation/compression ratio of 5:50 compared with 2:15 during BLS with an unsecured airway reduces the time until the first defibrillation and tracheal intubation was performed without changes in ventilation volume and compressions per minute. The Paramedics stated that the 5:50 ratio improved the work-flow and reduced the emotional stress. [Copyright &y& Elsevier]

Abstract: Objectives: The aim was to assess the knowledge of life-supporting first-aid in both cardiac arrest survivors and relatives, and their willingness to have a semi-automatic external defibrillator in their homes and use it in an emergency. Material and methods: Cardiac arrest survivors, their families, friends, neighbours and co-workers were interviewed by medical students using prepared questionnaires. Their knowledge and self-assessment of life-supporting first-aid, their willingness to have a semi-automatic defibrillator in their homes and their willingness to use it in an emergency before and after a course in cardiopulmonary resuscitation (CPR) with a semi-automatic external defibrillator was evaluated. Courses were taught by medical students who had received special training in basic and advanced life support. Results: Both patients and relatives, after a course of 2–3h, were no longer afraid of making mistakes by providing life-supporting first-aid. The automated external defibrillator (AED) was generally accepted and considered easy to handle. Conclusion: We consider equipping high-risk patients and their families with AEDs as a viable method of increasing their survival in case of a recurring cardiac arrest. This, of course, should be corroborated by further studies. [Copyright &y& Elsevier]

Introduction: It has long been observed that CPR skills rapidly decline regardless of the modality used for teaching or criteria used for testing. Uninterrupted chest compression CPR (UCC-CPR) is a proposed alternative to standard single rescuer CPR (STD-CPR) for laypersons in witnessed unexpected cardiac arrest in adults. It delivers substantially more compressions per minute and may be easier to remember and perform than standard CPR. Methods: In this prospective study, 28 medical students were taught STD-CPR and UCC-CPR and then were tested on each method at baseline (0), 6, and 18 months after training. The students’ performance for at least 90 s of CPR was evaluated based on video and Laerdal Skillreporter Resusci Anne recordings. Results: The mean number of correct chest compressions delivered per minute trended down over time in STD-CPR (23±3, 19±4, and 15±3; P = 0.09) but stayed the same in UCC-CPR (43±9, 38±7, and 37±7; P = 0.91) at 0, 6, and 18 months, respectively. The mean percentage of chest compressions delivered correctly fell over time in STD-CPR (54±6%, 35±6%, and 32±6%; P = 0.02) but stayed the same in UCC-CPR (34±5%, 41±7%, and 38±8%) at 0, 6, and 18 months, respectively. The number of chest compressions delivered per minute was higher in UCC-CPR at 0, 6, and 18 months (113 versus 44, P < 0.0001; 94 versus 47, P < 0.0001; and 92 versus 44, P < 0.001). The greater number of chest compressions was due to a mean ventilaroty pause of 13–14 s during STD-CPR at all three time points. Conclusions: Chest compression performance during STD-CPR declined in repeated testing over 18 months whereas there was minimal decline in chest compressions performance on repeated testing of UCC-CPR. In addition, substantially more chest compressions were delivered during UCC-CPR compared to STD-CPR at all time points primarily because of long pauses accompanying rescue breathing. [Copyright &y& Elsevier]

A short and effective training programme is an essential prerequisite for the use of automated external defibrillators (AED) by EMS providers and first responders. We evaluated a 3-h AED course based on the ERC requirements. Methods: As part of a study evaluating the effectiveness of AEDs used by first responders (ARREST 4), we trained all police officers in the region of Amsterdam, the Netherlands. By means of a Basic Life Support (BLS) assessment at the beginning of the course and at the end, we evaluated whether BLS can be improved in a 3-h AED course. Through a combined BLS and AED assessment at the end of the course, we evaluated whether AED skills can be acquired sufficiently. BLS skills were measured with the Laerdal SkillMeter™ in evaluation mode. AED skills were assessed using 13 criteria. By means of logistic regression, we analysed the influence of student characteristics, such as age, gender, previous training, resuscitation experience and motivation for BLS and AED on BLS and AED skills acquisition. Results: Between September 1999 and June 2000, 823 police officers were trained (76% male, mean age 36 (S.D. 9) years). BLS improved significantly (P<0.001) in all criteria, except for hypoventilation (P<0.001). After training, 89% of the students were able to use an AED safely and effectively. Self-confidence and motivation improved from 12 and 73% to 99 and 94% over the course (P<0.001). Independent student characteristics influencing the success of the AED course were: previous BLS training, motivation before the course for an AED, and resuscitation experience that dated back for more than 12 months. Conclusion: The majority of police officers can be trained to use an AED safely and effectively within a 3-h AED course. During this course, they also improve on their BLS skills. Successful completion of the course depends in part on the student characteristics. [Copyright &y& Elsevier]

Background: The bystander is often the first person present at the scene of an accident. Our aim was to determine how often and how well bystanders perform trauma care and whether trauma care is affected by the bystander’s level of training, relationship to the patient and numbers of bystanders present. Patients and methods: In a prospective 1-year study, the emergency medical service in two European cities collected data on trauma calls. Questionnaires were used to document the bystanders’ level of training (none, basic, advanced, professional), the bystander’s relationship to the patient, and the number of bystanders present, and to assess whether five separate measures of trauma care (ensuring scene safety, extrication of the patient, positioning, control of haemorrhage, prevention of hypothermia) were performed correctly, incorrectly, or not at all. Results: Two thousand nine hundred and thirty-two trauma calls were documented and bystanders were present in 1720 (58.7%). All measures except ensuring scene safety and prevention of hypothermia were affected by the bystander’s level of training. Correct extrication, positioning, and control of haemorrhage increased with the level of bystander training while the number of patients who were not attended decreased (P<0.05, P<0.005, P<0.005), respectively. The relationship to the patient did not affect whether, or how well, any measure was performed. The number of bystanders present only affected prevention of hypothermia, which was performed most often when only one bystander was present. Conclusion: Improved, more widespread training could increase the frequency and quality of bystander trauma care further. [Copyright &y& Elsevier]

Standard cardiopulmonary resuscitation (CPR) may be difficult to perform in a confined space. This study set out to evaluate alternative techniques of chest compression, which may be easier to perform in such situations. Nineteen airline employees, trained in basic life support (BLS), were recruited to take part in the study. Following refresher training in standard one- and two-person CPR, they were taught two alternative techniques of chest compression: one-person over-the-head (OTH) and two-person straddle (STR). Their performances of chest compression during one-person standard CPR (St-1) and two-person standard CPR (St-2) were then compared with their performances during OTH and STR using a recording manikin. There were no statistically significant differences between the two-person methods of compression (St-2 and STR) for any of the parameters measured. There were no statistically significant differences between the one-person methods of chest compression (St-1 and OTH) for the average compression rate, the number of chest compressions achieved in a minute, or the average hands-off time per cycle. For OTH the average compression depth was significantly less than for St-1 (P=0.0149) and there were more compressions of incorrect depth (P=0.0400). The average duty cycle was significantly higher for OTH (P=0.0045). 30.4% of compressions were incorrectly placed for OTH compared with 7.7% for St-1 (P=0.0025). It was concluded that the quality of chest compression during two-person straddle CPR compares favorably with chest compression during standard two-person CPR, and may be useful in situations where space is limited. If only one rescuer is available to perform CPR, and limited space makes it impossible to carry out standard CPR, over-the-head CPR is an alternative method. However, in this study, hand placement during chest compression was poor, and additional training may be necessary before it can be considered a safe technique. [Copyright &y& Elsevier]

At the scene of an accident, the most severely injured patients need trauma care urgently. Bystanders are often present before the emergency medical service arrives and may be able to limit trauma-related damage by providing trauma care at the scene. The aim of this prospective study conducted in Mainz, Germany, and Vienna, Austria, was to compare the frequency and quality of bystander trauma care in moderately versus severely injured patients. Five specific measures (making the scene readily visible for oncoming traffic, extrication and positioning of the trauma patient, control of haemorrhage, and hypothermia protection) were assessed in a questionnaire and evaluated statistically. Bystanders were present at the scene in 58.7% of all accidents. Making the scene readily visible for oncoming traffic, patient extrication and patient positioning were initiated significantly more often than haemorrhage control and hypothermia protection. Extrication, patient positioning and hypothermia protection were initiated significantly more often in moderately (NACA I-II) compared to severely (NACA III-VII) injured patients. In severely injured patients, bystanders attempted measures less frequently and the measures performed were more often incorrect compared to those in moderately injured patients. Our findings show that severely injured patients received less and less appropriate bystander trauma care than moderately injured patients. In an effort to correct this serious problem and to improve trauma care on-scene, we advocate offering lay persons more extensive training in bystander trauma care. [Copyright &y& Elsevier]

Objectives: To assess the frequency of use of basic life support (BLS) skills among hospital staff of all disciplines. Design: Postal survey of 9600 teaching hospital staff. Participants: 3807 respondents from all disciplines. Main outcome measures: Frequency of attendance, and the use of BLS skills, at patients with cardiopulmonary arrest. Results: Most respondents reported having attended BLS training previously: 27.9% in the prior 6 months; 24.5% 6–12 months previously; 17.1% over 1 year ago; and 11.5% over 2 years ago. 17.1% reported never having received BLS training. 1.9% gave no valid response. Nearly half of all respondents had never attended a cardiopulmonary arrest. Among those most likely to have attended, i.e. qualified nursing and medical staff, the median frequency of attendance was less than once per year. Ventilation delivered using a pocket mask or bag-valve-mask was reported by 9.4 and 29.2% of respondents, respectively. Less than 7% reported the use of mouth-to-mouth ventilation. Only among qualified nursing (8.8%) and medical (24.7%) staff did this proportion exceed 5%. The vast majority of non-qualified nursing staff (84.9%), allied health professionals (86%) and administrative and clerical staff (98%) had used neither chest compressions nor mouth-to-mouth ventilation. Conclusions: Some skills taught during BLS training are used infrequently in the in-hospital situation. The likelihood of attendance at arrest events and of the use of BLS skills is extremely low among some identified professional groups. BLS skills teaching should be targeted at those groups most likely to actually use them in order to make best use of the resources available. [Copyright &y& Elsevier]

This randomised controlled trial used a manikin model of cardiac arrest to compare skill performance in untrained lay persons randomised to receive either compression-only telephone CPR (Compression-only tel., n=29) or standard telephone CPR instructions (Standard tel., n=30). Performance was evaluated during standardised 10 min cardiac arrest simulations using a video recording and data from a laptop computer connected to the training manikin. A number of subjects in both groups did not open the airway. More than 75% in the Standard tel. group failed to deliver two effective initial rescue breaths, and only 17% provided an adequate inflation volume for subsequent breaths, delivering a median of only five inflations during the entire scenario. Most subjects in both groups gave chest compressions that were too shallow and at an inappropriately rapid rate. Hand position was also poor, but was worse in the group given simplified instructions. There was a significant delay to first compression in both groups, although this interval was shortened by over a minute when ventilations were eliminated from the telephone instruction algorithm (245 vs. 184 s, P<0.001). Over two-and-a-half times as many chest compressions were delivered during an average ambulance response time with compression-only telephone directions compared with standard CPR (461 vs. 186, P<0.001). These variables may be critical in predicting survival from out-of-hospital cardiac arrest. Further research is necessary to establish if modifications to scripted telephone instructions can remedy the identified performance deficiencies. Eliminating instructions for rescue breaths from scripted telephone directions will have little impact on the ventilation of most patients. Research is required to determine if the consequent reduction in the delay to starting chest compressions and the significant increase in the number of compressions delivered can increase survival from out-of-hospital cardiac arrest. [Copyright &y& Elsevier]

Objectives: To describe the plan and development of a programme for the introduction of automated external defibrillation for non medical personnel and to report the results of the first 10 months of activity in a community which is predominently rural, such as Galicia.Methods: The plan for introduction of the project included aspects of logistics, training and control. We studied cardiac arrests, that were treated in basic life support ambulances (BLS-A) equipped with automated external defibrillators (AEDs), from 1st March to 31st December 2001.Results: Our community benefits from pioneering legislation in Spain. During the 10 months of study, 28 AEDs were in service, mostly in urban areas. In all cases, a thorough control of the quality of the service in which AEDs was used was carried out. 12% of the patients, who were victims of sudden cardiac death (SCD) and were found in ventricular fibrillation (VF), survived and were discharged from hospital. However, the percentage of patients found in VF is only around 26%. This is due to long assistance intervals (from the call to the arrival on site), and an important delay from the moment when circulatory collapse takes place until the emergency service 061 is called, more than 5 min in half the cases.Conclusions: The programme followed for the introduction of AEDs in Galicia was adapted to the socio-demographic characteristics of the population. The prehospital emergency assistance model was developed, executed and controlled by the Public Emergency Health Foundation of Galicia 061 (PEHF-061). The overall results of our first 10 months experience with the automated external defibrillation programme were as to be expected. In general, they are comparable to other published reports; however, ways of shortening the times from the point of collapse to defibrillation must be found, mainly by training the population and through the extension of automated external defibrillation provision to other first responders. [ABSTRACT FROM AUTHOR]