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Background Little is known about how COVID‐19 influenced engagement of citizen responders dispatched to out‐of‐hospital cardiac arrest (OHCA) by a smartphone application. The objective was to describe and analyze the Danish Citizen Responder Program and bystander interventions (both citizen responders and nondispatched bystanders) during the first COVID‐19 lockdown in 2020. Methods and Results All OHCAs from January 1, 2020, to June 30, 2020, with citizen responder activation in 2 regions of Denmark were included. We compared citizen responder engagement for OHCA in the nonlockdown period (January 1, 2020, to March 10, 2020, and April 21, 2020, to June 30, 2020) with the lockdown period (March 11, 2020, to April 20, 2020). Data are displayed in the order lockdown versus nonlockdown period. Bystander cardiopulmonary resuscitation rates did not differ in the 2 periods (99% versus 92%; P =0.07). Bystander defibrillation (9% versus 14%; P =0.4) or return‐of‐spontaneous circulation (23% versus 23%; P =1.0) also did not differ. A similar amount of citizen responders accepted alarms during the lockdown (6 per alarm; interquartile range, 6) compared with the nonlockdown period (5 per alarm; interquartile range, 5) ( P =0.05). More citizen responders reported performing chest‐compression‐only cardiopulmonary resuscitation during lockdown compared with nonlockdown (79% versus 59%; P =0.0029), whereas fewer performed standardized cardiopulmonary resuscitation, including ventilations (19% versus 38%; P =0.0061). Finally, during lockdown, more citizen responders reported being not psychologically affected by attending an OHCA compared with nonlockdown period (68% versus 56%; P P =0.003). Conclusions The COVID‐19 lockdown in Denmark was not associated with decreased bystander‐initiated resuscitation in OHCAs attended by citizen responders.

Extracorporeal cardiopulmonary resuscitation is the rapid deployment of extracorporeal life support during cardiac arrest and has emerged as a rescue therapy for refractory cardiac arrest. Systemic circulation and oxygenation are temporarily restored, such that medical efforts can be focussed on the diagnosis and treatment of the underlying cause of the arrest. Observational research has shown this may improve survival with good neurological outcome. Crucial in resuscitation is the interval between arrest and return of circulation. Four factors are of influence during this phase: 1) witnessed arrest, 2) no-flow duration, 3) bystander basic life support, and 4) low-flow duration. The purpose of this review is to describe the current level of evidence for these factors in conventional and extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest. Underreporting and national variability of the pre-hospital links in the chain-of-survival is prevalent. Consistent reporting is essential for new trials to enable comparison and generalisation to other regions.

Background We aim to examine diurnal and weekday variations in citizen responder availability and intervention at out‐of‐hospital cardiac arrest (OHCA) resuscitation. Methods and Results We included confirmed OHCAs where citizen responders were activated by a smartphone application in the Capital Region of Denmark between September 1, 2017 and August 31, 2018. OHCAs were analyzed by time of day (daytime: 07:00 am –03:59 pm , evening: 4:00–11:59 pm , and nighttime: 12:00–06:59 am ) and day of week (Monday–Friday or Saturday–Sunday/public holidays). We included 438 OHCAs where 6836 citizen responders were activated. More citizen responders accepted alarms in the evening (mean 4.8 [95% CI, 4.4–5.3]) compared with daytime (3.7 [95% CI, 3.4–4.4]) and nighttime (1.8 [95% CI, 1.5–2.2]) ( P P P P =0.002). When responders arrived before Emergency Medical Services, there was no difference of bystander cardiopulmonary resuscitation or defibrillation between daytime, evening, and nighttime ( P =0.75 and P =0.22, respectively) or between weekend and weekdays ( P =0.29 and P =0.12, respectively). Conclusions Citizen responders were more likely to accept OHCA alarms during evening and weekends, with the highest proportion of responders arriving before Emergency Medical Services in the evening. However, there was no significant difference in delivering cardiopulmonary resuscitation or early defibrillation among cases where citizen responders arrived before Emergency Medical Services. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03835403.

Background: Cardiopulmonary resuscitation (CPR) improves cardiac arrest survival. Cough CPR, percussion pacing and precordial thump have been reported as alternative CPR techniques. We aimed to summarise in a systematic review the effectiveness of these alternative CPR techniques. Methods: We searched Ovid MEDLINE, EMBASE and the Cochrane Library on 24/08/2020. We included randomised controlled trials, observational studies and case series with five or more patients. Two reviewers independently reviewed title and abstracts to identify studies for full-text review, and reviewed bibliographies and 'related articles' (using PubMed) of full-texts for further eligible studies. We extracted data and performed risk-of-bias assessments on studies included in the systematic review. We summarised data in a narrative synthesis, and used GRADE to assess evidence certainty. Results: We included 23 studies (cough CPR n = 4, percussion pacing n = 4, precordial thump n = 16; one study studied two interventions). Only two (both precordial thump) had a comparator group ('standard' CPR). For all techniques evidence certainty was very low. Available evidence suggests that precordial thump does not improve survival to hospital discharge in out-of-hospital cardiac arrest. The review did not find evidence that cough CPR or percussion pacing improve clinical outcomes following cardiac arrest. Conclusion: Cough CPR, percussion pacing and precordial thump should not be routinely used in established cardiac arrest. In specific inpatient, monitored settings cough CPR (in conscious patients) or percussion pacing may be attempted at the onset of a potential lethal arrhythmia. These must not delay standard CPR efforts in those who lose cardiac output.

Introduction: Chest compression quality during in-hospital resuscitation is often suboptimal on a soft surface. Scientific evidence regarding the effectiveness of a backboard is scarce. This single-blinded manikin study evaluated the effect of a backboard on compression depth, rate and chest recoil performed by nurses. Sex, BMI, age and clinical department were considered as potential predictors. Methods: Using self-learning, nurses were retrained to achieve a minimal combined compression score at baseline. This combined score consisted of >= 70% compressions with depth 50-60 mm, >= 70% compressions with complete release (= 70%. Results: In total 278 nurses were retrained, 158 nurses dropped out and 120 were allocated to the backboard (n = 61) or control group (n = 59). The proportion of participants achieving a combined compression score of >= 70% was not significantly different (p = 0.475) and suboptimal in both groups: backboard group 47.5% (backboard) versus 41.0% (control). Older age (>= 51 years) was associated with a lower probability of achieving a combined compression score >70% [OR = 0.133; 95% confidence interval (CI), 0.037-0.479; p = 0.002]. Conclusion: Using a backboard did not significantly improve compression quality in our study. Important decay of compression skills was observed in both groups, highlighting the importance of frequent retraining, particularly in some age groups.

BackgroundWith the “Artemis”-mission mankind will return to the Moon by 2024. Prolonged periods in space will not only present physical and psychological challenges to the astronauts, but also pose risks concerning the medical treatment capabilities of the crew. So far, no guideline exists for the treatment of severe medical emergencies in microgravity. We, as a international group of researchers related to the field of aerospace medicine and critical care, took on the challenge and developed a an evidence-based guideline for the arguably most severe medical emergency – cardiac arrest.MethodsAfter the creation of said international group, PICO questions regarding the topic cardiopulmonary resuscitation in microgravity were developed to guide the systematic literature research. Afterwards a precise search strategy was compiled which was then applied to “MEDLINE”. Four thousand one hundred sixty-five findings were retrieved and consecutively screened by at least 2 reviewers. This led to 88 original publications that were acquired in full-text version and then critically appraised using the GRADE methodology. Those studies formed to basis for the guideline recommendations that were designed by at least 2 experts on the given field. Afterwards those recommendations were subject to a consensus finding process according to the DELPHI-methodology.ResultsWe recommend a differentiated approach to CPR in microgravity with a division into basic life support (BLS) and advanced life support (ALS) similar to the Earth-based guidelines. In immediate BLS, the chest compression method of choice is the Evetts-Russomano method (ER), whereas in an ALS scenario, with the patient being restrained on the Crew Medical Restraint System, the handstand method (HS) should be applied. Airway management should only be performed if at least two rescuers are present and the patient has been restrained. A supraglottic airway device should be used for airway management where crew members untrained in tracheal intubation (TI) are involved.DiscussionCPR in microgravity is feasible and should be applied according to the Earth-based guidelines of the AHA/ERC in relation to fundamental statements, like urgent recognition and action, focus on high-quality chest compressions, compression depth and compression-ventilation ratio. However, the special circumstances presented by microgravity and spaceflight must be considered concerning central points such as rescuer position and methods for the performance of chest compressions, airway management and defibrillation.

Background Internationally, the majority of out-of-hospital cardiac arrests where resuscitation is attempted (OHCAs) occur in private residential locations i.e. at home. The prospect of survival for this patient group is universally dismal. Understanding of the area-level factors that affect the incidence of OHCA at home may help national health planners when implementing community resuscitation training and services. Methods We performed spatial smoothing using Bayesian conditional autoregression on case data from the Irish OHCA register. We further corrected for correlated findings using area level variables extracted and constructed for national census data. Results We found that increasing deprivation was associated with increased case incidence. The methodology used also enabled us to identify specific areas with higher than expected case incidence. Conclusions Our study demonstrates novel use of Bayesian conditional autoregression in quantifying area level risk of a health event with high mortality across an entire country with a diverse settlement pattern. It adds to the evidence that the likelihood of OHCA resuscitation events is associated with greater deprivation and suggests that area deprivation should be considered when planning resuscitation services. Finally, our study demonstrates the utility of Bayesian conditional autoregression as a methodological approach that could be applied in any country using registry data and area level census data. Electronic supplementary material The online version of this article (10.1186/s12942-018-0126-z) contains supplementary material, which is available to authorized users.

The International Liaison Committee on Resuscitation has initiated a near-continuous review of cardiopulmonary resuscitation science that replaces the previous 5-year cyclic batch-and-queue approach process. This is the first of an annual series of International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations summary articles that will include the cardiopulmonary resuscitation science reviewed by the International Liaison Committee on Resuscitation in the previous year. The review this year includes 5 basic life support and 1 paediatric Consensuses on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Each of these includes a summary of the science and its quality based on Grading of Recommendations, Assessment, Development, and Evaluation criteria and treatment recommendations. Insights into the deliberations of the International Liaison Committee on Resuscitation task force members are provided in Values and Preferences sections. Finally, the task force members have pri-oritised and listed the top 3 knowledge gaps for each population, intervention, comparator, and outcome question. (C) 2017 European Resuscitation Council and American Heart Association, Inc. Published by Elsevier B.V. All rights reserved.

International audience; Introduction: Bag-valve-mask ventilation is the first-line ventilation method during cardiopulmonary resuscitation (CPR). Risks include excessive volume delivery and gastric insufflation, the latter increasing the risk of pneumonia. The efficacy of ventilation can also be reduced by airway closure. We hypothesized that continuous chest compression (CC) could limit the risk of gastric insufflation compared to the recommended 30:2 interrupted CC strategy. This experimental study was performed in human "Thiel" cadavers to assess the respective impact of discontinuous vs. continuous chest compressions on gastric insufflation and ventilation during CPR.Methods: The 30:2 interrupted CC technique was compared to continuous CC in 5 non-intubated cadavers over a 6 min-period. Flow and Airway Pressure were measured at the mask. A percutaneous gastrostomy allowed measuring the cumulative gastric insufflated volume. Two additional cadavers were equipped with esophageal and gastric catheters instead of the gastrostomy.Results: For the 7 cadavers studied (4 women) median age of death was 79 [74-84] years. After 6 min of CPR, the cumulative gastric insufflation measured in 5 cadavers was markedly reduced during continuous CC compared to the interrupted CC strategy: (1.0 [0.8-4.1] vs. 5.9 [4.0-5.6] L; p < 0.05) while expired minute ventilation was slightly higher during continuous than interrupted CC (1.9 [1.4-2.8] vs. 1.6 [1.1-2.7] L/min; P < 0.05). In 2 additional cadavers, the progressive rise in baseline gastric pressure was lower during continuous CC than interrupted CC (1 and 2 cmH2O vs. 12 and 5.8 cmH2O).Conclusion: Continuous CC significantly reduces the volume of gas insufflated in the stomach compared to the recommended 30:2 interrupted CC strategy. Ventilation actually delivered to the lung is also slightly increased by the strategy.

Background Mechanical chest compression (CC) is currently suggested to deliver sustained high‐quality CC in a moving ambulance. This study compared the hemodynamic support provided by a mechanical piston device or manual CC during ambulance transport in a porcine model of cardiopulmonary resuscitation. Methods and Results In a simulated urban ambulance transport, 16 pigs in cardiac arrest were randomized to 18 minutes of mechanical CC with the LUCAS (n=8) or manual CC (n=8). ECG, arterial and right atrial pressure, together with end‐tidal CO 2 and transthoracic impedance curve were continuously recorded. Arterial lactate was assessed during cardiopulmonary resuscitation and after resuscitation. During the initial 3 minutes of cardiopulmonary resuscitation, the ambulance was stationary, while then proceeded along a predefined itinerary. When the ambulance was stationary, CC‐generated hemodynamics were equivalent in the 2 groups. However, during ambulance transport, arterial and coronary perfusion pressure, and end‐tidal CO 2 were significantly higher with mechanical CC compared with manual CC (coronary perfusion pressure: 43±4 versus 18±4 mmHg; end‐tidal CO 2 : 31±2 versus 19±2 mmHg, P P P Conclusions This model adds evidence in favor of the use of mechanical devices to provide ongoing high‐quality CC and tissue perfusion during ambulance transport.

Background The use of real-time feedback systems to guide rescuers during cardiopulmonary resuscitation (CPR) significantly contributes to improve adherence to published resuscitation guidelines. Recently, we designed a novel method for computing depth and rate of chest compressions relying solely on the spectral analysis of chest acceleration. That method was extensively tested in a simulated manikin scenario. The purpose of this study is to report the results of this method as tested in human out-of-hospital cardiac arrest (OHCA) cases. Materials and methods The algorithm was evaluated retrospectively with seventy five OHCA episodes recorded by monitor-defibrillators equipped with a CPR feedback device. The acceleration signal and the compression signal computed by the CPR feedback device were stored in each episode. The algorithm was continuously applied to the acceleration signals. The depth and rate values estimated every 2-s from the acceleration data were compared to the reference values obtained from the compression signal. The performance of the algorithm was assesed in terms of the sensitivity and positive predictive value (PPV) for detecting compressions and in terms of its accuracy through the analysis of measurement error. Results The algorithm reported a global sensitivity and PPV of 99.98% and 99.79%, respectively. The median (P-75) unsigned error in depth and rate was 0.9 (1.7) mm and 1.0 (1.7) cpm, respectively. In 95% of the analyzed 2-s windows the error was below 3.5 mm and 3.1 cpm, respectively. Conclusions The CPR feedback algorithm proved to be reliable and accurate when tested retrospectively with human OHCA episodes. A new CPR feedback device based on this algorithm could be helpful in the resuscitation field. This work was supported by Gobierno Vasco-Eusko Jaularitza. Actividades de Grupos de Investigacion 2016 (http://www.hezkuntza.eigv.euskadi.eus/r43-5552/es/contenidos/informacion/dib4/es_2035/gsuv.c.html), grant number: IT1087-16, Principal investigator: Jesus Maria Ruiz. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Background and goal of study: The relationship between chest compression rate and compression depth is unknown. In order to characterise this relationship, we performed an observational study in prehospital cardiac arrest patients. We hypothesised that faster compressions are associated with decreased depth.Materials and methods: In patients undergoing prehospital cardiopulmonary resuscitation by health care professionals, chest compression rate and depth were recorded using an accelerometer (E-series monitor-defibrillator, Zoll, USA). Compression depth was compared for rates 120/min. A difference in compression depth >0.5 cm was considered clinically significant. Mixed models with repeated measurements of chest compression depth and rate (level 1) nested within patients (level 2) were used with compression rate as a continuous and as a categorical predictor of depth.Results are reported as means and standard error (SE). Results and discussion: One hundred and thirty-three consecutive patients were analysed (213,409 compressions). Of all compressions 2% were 120/min, 36% were 5 cm. In 77 out of 133 (58%) patients a statistically significant lower depth was observed for rates > 120/min compared to rates 80-120/min, in 40 out of 133 (30%) this difference was also clinically significant. The mixed models predicted that the deepest compression (4.5 cm) occurred at a rate of 86/min, with progressively lower compression depths at higher rates. Rates > 145/min would result in a depth 120/min (mean difference 0.4 cm, P Conclusions: This study showed an association between higher compression rates and lower compression depths. Avoiding excessive compression rates may lead to more compressions of sufficient depth. (C) 2012 Elsevier Ireland Ltd. All rights reserved.

Aims: This prospective longitudinal study over 6 years compared schoolteachers and emergency physicians as resuscitation trainers for schoolchildren. It also investigated whether pupils who were trained annually for 3 years retain their resuscitation skills after the end of this study. Methods: A total of 261 pupils (fifth grade) at two German grammar schools received resuscitation training by trained teachers or by emergency physicians. The annual training events stopped after 3 years in one group and continued for 6 years in a second group. We measured knowledge about resuscitation (questionnaire), chest compression rate (min-1), chest compression depth (mm), ventilation rate (min-1), ventilation volume (mL), self-efficacy (questionnaire). Their performance was evaluated after 1, 3 and 6 years. Results: The training events increased the pupils' knowledge and practical skills. When trained by teachers, the pupils achieved better results for knowledge (92.86% +/- 8.38 vs. 90.10% +/- 8.63, P = 0.04) and ventilation rate (4.84/min +/- 4.05 vs. 3.76/min +/- 2.37, P = 0.04) than when they were trained by emergency physicians. There were no differences with regard to chest compression rate, depth, ventilation volume, or self-efficacy at the end of the study. Knowledge and skills after 6 years were equivalent in the group with 6 years training compared with 3 years training. Conclusions: Trained teachers can provide adequate resuscitation training in schools. Health-care professionals are not mandatory for CPR training (easier for schools to implement resuscitation training). The final evaluation after 6 years showed that resuscitation skills are retained even when training is interrupted for 3 years. (C) 2016 The Authors. Published by Elsevier Ireland Ltd.

Quality of cardiopulmonary resuscitation (CPR) improves through the use of CPR feedback devices. Most feedback devices integrate the acceleration twice to estimate compression depth. However, they use additional sensors or processing techniques to compensate for large displacement drifts caused by integration. This study introduces an accelerometer-based method that avoids integration by using spectral techniques on short duration acceleration intervals. We used a manikin placed on a hard surface, a sternal triaxial accelerometer, and a photoelectric distance sensor (gold standard). Twenty volunteers provided 60 s of continuous compressions to test various rates (80-140 min(-1)), depths (3-5 cm), and accelerometer misalignment conditions. A total of 320 records with 35312 compressions were analysed. The global root-mean-square errors in rate and depth were below 1.5 min(-1) and 2 mm for analysis intervals between 2 and 5 s. For 3 s analysis intervals the 95% levels of agreement between the method and the gold standard were within -1.64-1.67 min(-1) and -1.69-1.72 mm, respectively. Accurate feedback on chest compression rate and depth is feasible applying spectral techniques to the acceleration. The method avoids additional techniques to compensate for the integration displacement drift, improving accuracy, and simplifying current accelerometer-based devices. This work received financial support from the Spanish Government (TEC2012-31144, TEC2012-31928), the Basque Government (Grants BFI-2010-174, BFI-2010-235, and BFI-2011-166), and the University of the Basque Country (unit UFI11/16). The authors would like to thank Dr. Jo Kramer-Johansen (Institute for Experimental Medical Research, Oslo, Norway) for his valuable suggestions on the paper.

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