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ImportanceThe administration of a high fraction of oxygen following return of spontaneous circulation in out-of-hospital cardiac arrest may increase reperfusion brain injury.ObjectiveTo determine whether targeting a lower oxygen saturation in the early phase of postresuscitation care for out-of-hospital cardiac arrest improves survival at hospital discharge.Design, Setting, and ParticipantsThis multicenter, parallel-group, randomized clinical trial included unconscious adults with return of spontaneous circulation and a peripheral oxygen saturation (Spo2) of at least 95% while receiving 100% oxygen. The trial was conducted in 2 emergency medical services and 15 hospitals in Victoria and South Australia, Australia, between December 11, 2017, and August 11, 2020, with data collection from ambulance and hospital medical records (final follow-up date, August 25, 2021). The trial enrolled 428 of a planned 1416 patients.InterventionsPatients were randomized by paramedics to receive oxygen titration to achieve an oxygen saturation of either 90% to 94% (intervention; n = 216) or 98% to 100% (standard care; n = 212) until arrival in the intensive care unit.Main Outcomes and MeasuresThe primary outcome was survival to hospital discharge. There were 9 secondary outcomes collected, including hypoxic episodes (Spo2 ResultsThe trial was stopped early due to the COVID-19 pandemic. Of the 428 patients who were randomized, 425 were included in the primary analysis (median age, 65.5 years; 100 [23.5%] women) and all completed the trial. Overall, 82 of 214 patients (38.3%) in the intervention group survived to hospital discharge compared with 101 of 211 (47.9%) in the standard care group (difference, −9.6% [95% CI, −18.9% to −0.2%]; unadjusted odds ratio, 0.68 [95% CI, 0.46-1.00]; P = .05). Of the 9 prespecified secondary outcomes collected during hospital stay, 8 showed no significant difference. A hypoxic episode prior to intensive care was observed in 31.3% (n = 67) of participants in the intervention group and 16.1% (n = 34) in the standard care group (difference, 15.2% [95% CI, 7.2%-23.1%]; OR, 2.37 [95% CI, 1.49-3.79]; P Conclusions and RelevanceAmong patients achieving return of spontaneous circulation after out-of-hospital cardiac arrest, targeting an oxygen saturation of 90% to 94%, compared with 98% to 100%, until admission to the intensive care unit did not significantly improve survival to hospital discharge. Although the trial is limited by early termination due to the COVID-19 pandemic, the findings do not support use of an oxygen saturation target of 90% to 94% in the out-of-hospital setting after resuscitation from cardiac arrest.Trial RegistrationClinicalTrials.gov Identifier: NCT03138005

his is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed. This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

PURPOSE OF REVIEW The purpose of this review is to provide an update for critical care clinicians and providers on the recent developments in patient and healthcare professional (HCP) resuscitation education. RECENT FINDINGS The family members of patients at high-risk of cardiac arrest need to be provided with access to basic life support (BLS) training. Many low-cost methods are now available to provide BLS training beyond attending a traditional BLS instructor-led cardiopulmonary resuscitation (CPR) class. Hybrid-blended learning formats provide new opportunities to receive individualized CPR-training in a flexible and convenient format. HCPs' participation in accredited advanced life support courses improves patient outcomes. Monitoring HCPs exposure to resuscitation and supplementing with frequent simulation is recommended. Training should include human factors and nontechnical skills. Volunteering for first responder programs when off-duty provides a great opportunity for HCP's to improve out-of-hospital cardiac arrest survival and increase exposure to resuscitation. SUMMARY Frequent resuscitation education and training is critical to improving cardiac arrest patient outcomes. Recent evidence shows the effectiveness of technological developments to improve access to training and outcomes.

Introduction: Early intervention of bystanders (the first links of the chain of survival) have been shown to improve survival and good neurological outcomes of patients suffering out-of-hospital cardiac arrest (OHCA). Many initiatives have been implemented to increase the engagement of communities in early basic life support (BLS) and cardiopulmonary resuscitation (CPR), especially of lay people with no duty to respond. A better knowledge of the most effective initiatives might help improve survival and health system organization. Aim of the scoping review: To assess the impact of specific interventions involving lay communities on bystander BLS rates and other consistent clinical outcomes, and to identify relevant knowledge gaps. Methods: This scoping review was part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR), and was performed following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. We performed a literature search using the PubMed, EMBASE, and Cochrane databases until 1 February 2021. The screening process was conducted based on predefined inclusion/exclusion criteria, and for each included study, we performed data extraction focusing on the type of intervention implemented, and the impact of these interventions on the specific OHCAs outcomes. Results: Our search strategy identified 19 eligible studies, originating mainly from the USA (47.4%) and Denmark (21%). The type of intervention included in 57.9% of cases was a community CPR training program, in 36.8% bundled interventions, and in 5.3% mass-media campaigns. The most commonly reported outcome for OHCAs was bystander CPR rate (94.7%), followed by survival to hospital discharge (36.8%), proportion of people trained (31.6%), survival to hospital discharge with good neurological outcome (21%), and Return of Spontaneous Circulation (10.5%). Community training programs and bundled interventions improved bystander CPR in most of the included studies. Conclusion: Based on the results of our scoping review, we identified the potential benefit of community initiatives, such as community training in BLS, even as part of bundled intervention, in order to improve bystander CPR rates and patient outcomes.

IntroductionOut-of-hospital cardiac arrest (OHCA) is associated with poor survival outcomes, but prompt bystander action can more than double survival rates. Being trained, confident and willing-to-perform cardiopulmonary resuscitation (CPR) are known predictors of bystander action. This study aims to assess the effectiveness of a community organisation targeted multicomponent education and training initiative on being willing to respond to OHCAs. The study employs a novel approach to reaching community members via social and cultural groups, and the intervention aims to address commonly cited barriers to training including lack of availability, time and costs.Methods and analysisFirstCPR is a cluster randomised trial that will be conducted across 200 community groups in urban and regional Australia. It will target community groups where CPR training is not usual. Community groups (clusters) will be stratified by region, size and organisation type, and then randomly assigned to either immediately receive the intervention programme, comprising digital and in-person education and training opportunities about CPR and OHCA over 12 months, or a delayed programme implementation. The primary outcome is self-reported ‘training and willingness-to-perform CPR’ at 12 months. It will be assessed through surveys of group members that consent in intervention versus control groups and administered prior to control groups receiving the intervention. The primary analysis will follow intention-to-treat principles, use log binomial regression accounting for baseline covariates and be conducted at the individual level, while accounting for clustering within communities. Focus groups and interviews will be conducted to examine barriers and enablers to implementation and costs will also be examined.Ethics and disseminationEthical approval was obtained from The University of Sydney. Findings from this study will be disseminated via presentations at scientific conferences, publications in peer-reviewed journals, scientific and lay reports.Trial registration numberACTRN12621000367842.

Despite significant advances in the field of resuscitation science, important knowledge gaps persist. Current guidelines for resuscitation are based on the International Liaison Committee on Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, which includes treatment recommendations supported by the available evidence. The writing group developed this consensus statement with the goal of focusing future research by addressing the knowledge gaps identified during and after the 2015 International Liaison Committee on Resuscitation evidence evaluation process. Key publications since the 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations are referenced, along with known ongoing clinical trials that are likely to affect future guidelines. © 2018 European Resuscitation Council and American Heart Association, Inc. Published by Elsevier B.V. All rights reserved.

Introduction: Outpatient cardiac rehabilitation programs provide an ideal environment to deliver targeted cardiopulmonary resuscitation (CPR) training to cardiac patients and their family members. However, the prevalence of CPR training in Australian programs is low (24%). This study sought to identify the best strategy to implement CPR training into cardiac rehabilitation programs. Hypothesis: We hypothesise that coordinators who receive a higher level of education (information pack including two self-instructional CPR video training kits and a face-to-face education session) compared to those who only receive an information pack, will be more likely to incorporate CPR training into their cardiac rehabilitation programs. Methods: A two-arm randomised controlled implementation study is currently being conducted across Australia. One cardiac rehabilitation coordinator per cardiac rehabilitation program, where the program is not currently providing regular CPR training to patients and families, is eligible to participate. Coordinators will be randomised 1:1 to either receive an information pack or information pack plus face-to-face education session. Results: To date 23 coordinators (59% metropolitan programs, 41% rural programs) have been randomised. Few programs (19%) have previously offered CPR training and only 25% currently include information about CPR. Common barriers to incorporating CPR training into programs are time (71%), resources (67%) and a lack of awareness to include CPR training (24%). Motivations for including CPR training are driven by coordinators assessment that patients and families are interested in CPR training (81%). Implementation data will be presented including information on the level of implementation in addition to a sample of brief qualitative telephone interviews to further discuss enablers and barriers. Conclusions: Cardiac rehabilitation represents a logical location to provide targeted CPR training to high-risk cardiac groups at scale across Australia. This study will aid in better understanding how cardiac rehabilitation coordinators can be supported to enable more programs to incorporate CPR training.

In 2010, rapid access to stroke thrombolysis centres was limited in some regional areas in the Australian state of Victoria. These results, and planning for endovascular clot retrieval (ECR), have led to the implementation of strategies by the Victorian Stroke Clinical Network, the Victorian Stroke Telemedicine Program and local health services to improve state-wide access.To examine whether access to stroke reperfusion services (thrombolysis and ECR) in regional Victoria have subsequently improved.The locations of suspected stroke patients attended by ambulance in 2015 were mapped, and drive times to the nearest reperfusion services were calculated. We then calculated the proportion of cases with transport times within: (i) 60 min to thrombolysis centres; and (ii) 180 min to two ECR centres designated to receive regional patients. Statistical comparisons to existing 2010 data were made.In 2015, Ambulance Victoria attended 16 418 cases of suspected stroke (2.9% of all emergency calls), of whom 4597 (28%) were located in regional Victoria. Compared to 2010, a greater proportion of regional suspected stroke patients in 2015 were located within 60 min of a thrombolysis centre by road (77-95%, P0.001). A 3-h road travel time to the two ECR centres is currently possible for 88% of regional patients.A strategic and region-specific approach has resulted in improved access by road transport to reperfusion therapies for stroke patients across Victoria.

To provide contemporary Australian data on the public's training in cardiopulmonary resuscitation (CPR) and awareness of hands-only CPR.A cross-sectional telephone survey in April 2016 of adult residents of the Australian state of Victoria was conducted. Primary outcomes were rates of CPR training and awareness of hands-only CPR.Of the 404 adults surveyed (mean age 55 ± 17 years, 59% female, 73% metropolitan residents), 274 (68%) had undergone CPR training. Only 50% (n = 201) had heard of hands-only CPR, with most citing first-aid courses (41%) and media (36%) as sources of information. Of those who had undergone training, the majority had received training more than 5 years previously (52%) and only 28% had received training or refreshed training in the past 12 months. Most received training in a formal first-aid class (43%), and received training as a requirement for work (67%). The most common reasons for not having training were: they had never thought about it (59%), did not have time (25%) and did not know where to learn (15%). Compared to standard CPR, a greater proportion of respondents were willing to provide hands-only CPR for strangers (67% vs 86%, P0.001).From an Australian perspective, there is still room for improvement in CPR training rates and awareness of hands-only CPR. Further promotion of hands-only CPR and self-instruction (e.g. DVD kits or online) may see further improvements in CPR training and bystander CPR rates.

The present study aimed to describe and examine similarities and differences in the current service provision and resuscitation protocols of the ambulance services participating in the Aus-ROC Australian and New Zealand out-of-hospital cardiac arrest (OHCA) Epistry. Understanding these similarities and differences is important in identifying ambulance service factors that might explain regional variation in survival of OHCA in the Aus-ROC Epistry.A structured questionnaire was completed by each of the ambulance services participating in the Aus-ROC Epistry. These ambulance services were SA Ambulance Service, Ambulance Victoria, St John Ambulance Western Australia, Queensland Ambulance Service, St John Ambulance NT, St John New Zealand and Wellington Free Ambulance. The survey aimed to describe ambulance service and dispatch characteristics, resuscitation protocols and details of cardiac arrest registries.We observed similarities between services with respect to the treatment of OHCA and dispatch systems. Differences between services were observed in the serviced population; the proportion of paramedics with basic life support, advanced life support or intensive care training skills; the number of OHCA cases attended; guidelines related to withholding or terminating resuscitation attempts; and the variables that might be used to define 'attempted resuscitation'. All seven participating ambulance services were noted to have existing OHCA registries.There is marked variation between ambulance services currently participating in the Aus-ROC Australian and New Zealand OHCA Epistry with respect to workforce characteristics and key variable definitions. This variation between ambulance services might account for a proportion of the regional variation in survival of OHCA.

We have previously established that paramedic exposure to out-of-hospital cardiac arrest (OHCA) is relatively rare, therefore clinical exposure cannot be relied on to maintain resuscitation competency. We aimed to identify the current practices within emergency medical services (EMS) for developing and maintaining paramedic resuscitation competency.We developed and conducted an online cross-sectional survey of Australian and New Zealand EMS in 2015. The survey was piloted by one EMS and targeted at education managers.A total of nine of the 10 EMS responded to the survey. All EMS reported that they provide resuscitation training to paramedics at the commencement of their employment (median 16 h, interquartile range [IQR]: 7-80). With the exception of one EMS that did not provide any refresher training, a median of 4 h (IQR: 1-7) resuscitation training was provided to paramedics annually. All EMS used cardiac arrest simulations and skill stations to train paramedics. Paramedic exposure to OHCA was not taken into account to determine their training needs. Resuscitation competency was tested by EMS: annually (3/9), biennially (4/9) or not at all (2/9). Two EMS used CPR-feedback devices in clinical practice and only one EMS regularly performed formal debriefing after OHCA cases. Barriers to resuscitation competency included: difficulty removing paramedics from clinical duties for training and a lack of paramedic exposure to OHCA.All of the surveyed EMS provided initial resuscitation training to paramedics, but competency testing and refresher training practices varied between services. A lack of individual exposure to cardiac arrest and training time were identified as barriers to resuscitation competency.

To compare chief complaints of the Medical Priority Dispatch System in terms of the match between dispatch priority and patient condition.This was a retrospective whole-of-population study of emergency ambulance dispatch in Perth, Western Australia, 1 January 2014 to 30 June 2015. Dispatch priority was categorised as either Priority 1 (high priority), or Priority 2 or 3. Patient condition was categorised as time-critical for patient(s) transported as Priority 1 to hospital or who died (and resuscitation was attempted by paramedics); else, patient condition was categorised as less time-critical. The χThere were 211 473 cases of dispatch. Of 99 988 cases with Priority 2 or 3 dispatch, 467 (0.5%) were time-critical. Convulsions/seizures and breathing problems were highlighted as having more false negatives (time-critical despite Priority 2 or 3 dispatch) than expected from the overall false omission rate. Of 111 485 cases with Priority 1 dispatch, 6520 (5.8%) were time-critical. Our analysis highlighted chest pain, heart problems/automatic implanted cardiac defibrillator, unknown problem/collapse, and headache as having fewer true positives (time-critical and Priority 1 dispatch) than expected from the overall positive predictive value.Scope for reducing under-triage and over-triage of ambulance dispatch varies between chief complaints of the Medical Priority Dispatch System. The highlighted chief complaints should be considered for future research into improving ambulance dispatch system performance.

Current evidence demonstrates considerable variability in cardiac arrest survival in and out of hospital and, therefore, substantial opportunity to save many more lives.1–3 The Formula for Survival4 postulates that optimal survival from cardiac arrest requires high-quality science, education of lay providers and healthcare professionals, and a well-functioning Chain of Survival5 (implementation). The Education, Implementation, and Teams (EIT) Task Force of the International Liaison Committee on Resuscitation (ILCOR) set out to define the key PICO (population, intervention, comparator, outcome) questions related to resuscitation education (including teamwork skills) and systems-level implementation that would be reviewed by 2015. The selection of questions was supported through the use of an online anonymous task force member–only voting process where the results were considered in the ultimate consensus decisions of the task force. Topics from the 2010 evidence review process were scrutinized for relevance, the potential to improve outcomes, and the likelihood of new evidence being published since 2010. Finally, PICO questions for which the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) process was not as well developed at the time of PICO selection were deferred until at least after the 2015 cycle. We planned to reduce the total number of PICO questions reviewed to provide more in-depth and evidence-based reviews of the included questions. New topics were determined on the basis of the evolving literature and changes in resuscitation practice. Input on the selection of PICO questions was sought from the general public through the ILCOR website and from ILCOR member resuscitation councils through their council chairs and individual task force members. The EIT Task Force performed detailed systematic reviews based on the recommendations of the Institute of Medicine of the National Academies6 and using the methodological approach proposed by the …

Background— Oxygen is commonly administered to patients with ST-elevation–myocardial infarction despite previous studies suggesting a possible increase in myocardial injury as a result of coronary vasoconstriction and heightened oxidative stress. Methods and Results— We conducted a multicenter, prospective, randomized, controlled trial comparing oxygen (8 L/min) with no supplemental oxygen in patients with ST-elevation–myocardial infarction diagnosed on paramedic 12-lead ECG. Of 638 patients randomized, 441 patients had confirmed ST-elevation–myocardial infarction and underwent primary end-point analysis. The primary end point was myocardial infarct size as assessed by cardiac enzymes, troponin I, and creatine kinase. Secondary end points included recurrent myocardial infarction, cardiac arrhythmia, and myocardial infarct size assessed by cardiac magnetic resonance imaging at 6 months. Mean peak troponin was similar in the oxygen and no oxygen groups (57.4 versus 48.0 μg/L; ratio, 1.20; 95% confidence interval, 0.92–1.56; P =0.18). There was a significant increase in mean peak creatine kinase in the oxygen group compared with the no oxygen group (1948 versus 1543 U/L; means ratio, 1.27; 95% confidence interval, 1.04–1.52; P =0.01). There was an increase in the rate of recurrent myocardial infarction in the oxygen group compared with the no oxygen group (5.5% versus 0.9%; P =0.006) and an increase in frequency of cardiac arrhythmia (40.4% versus 31.4%; P =0.05). At 6 months, the oxygen group had an increase in myocardial infarct size on cardiac magnetic resonance (n=139; 20.3 versus 13.1 g; P =0.04). Conclusion— Supplemental oxygen therapy in patients with ST-elevation–myocardial infarction but without hypoxia may increase early myocardial injury and was associated with larger myocardial infarct size assessed at 6 months. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01272713.

Background and Purpose— The aim of this study was to examine the reach and impact of the National Stroke Foundation (NSF) multimedia stroke warning sign campaigns across Australia. Methods— A total of 12 439 surveys were performed across 6 states during 6 years on random state–weighted samples of Australians ≥40 years old. Results— Awareness of stroke advertising increased 31% to 50% between 2004 and 2010 ( P P P Conclusions— The Australian public’s awareness of stroke warning signs has improved since commencement of the NSF campaigns commensurate with greater awareness of stroke advertising. Public education efforts are worthwhile, and future efforts should focus on groups identified with low awareness or those at high risk of stroke.