Hands-only (compression-only) cardiopulmonary resuscitation: a call to action for bystander response to adults who experience out-of-hospital sudden cardiac arrest: a science advisory for the public from the American Heart Association Emergency Cardiovascular Care Committee

Disparities in Survival with Bystander CPR following Cardiopulmonary Arrest Based on Neighborhood Characteristics

The American Heart Association reports the annual incidence of out-of-hospital cardiopulmonary arrests (OHCA) is greater than 300,000 with a survival rate of 9.5%. Bystander cardiopulmonary resuscitation (CPR) saves one life for every 30, with a 10% decrease in survival associated with every minute of delay in CPR initiation. Bystander CPR and training vary widely by region. We conducted a retrospective study of 320 persons who suffered OHCA in South Florida over 25 months. Increased survival, overall and with bystander CPR, was seen with increasing income (p = 0.05), with a stronger disparity between low- and high-income neighborhoods (p = 0.01 and p = 0.03, resp.). Survival with bystander CPR was statistically greater in white- versus black-predominant neighborhoods (p = 0.04). Increased survival, overall and with bystander CPR, was seen with high- versus low-education neighborhoods (p = 0.03). Neighborhoods with more high school age persons displayed the lowest survival. We discovered a significant disparity in OHCA survival within neighborhoods of low-income, black-predominance, and low-education. Reduced survival was seen in neighborhoods with larger populations of high school students. This group is a potential target for training, and instruction can conceivably change survival outcomes in these neighborhoods, closing the gap, thus improving survival for all.

Are Canadians more willing to provide chest-compression-only cardiopulmonary resuscitation (CPR)?-a nation-wide public survey

BACKGROUND

Bystander cardiopulmonary resuscitation (CPR) improves the likelihood of survival from out-of-hospital cardiac arrest (OHCA), yet it is performed in only 30% of cases. The 2010 guidelines promote chest-compression-only bystander CPR-a change intended to increase willingness to provide CPR.

OBJECTIVES

1) To determine whether the Canadian general public is more willing to perform chest-compression-only CPR compared to traditional CPR; 2) to characterize public knowledge of OHCA; and 3) to identify barriers and facilitators to bystander CPR.

METHODS

A 32-item survey assessing resuscitation knowledge, and willingness to provide CPR were disseminated in five Canadian regions. Descriptive statistics were used to characterize response distribution. Logistic regression analysis was applied to assess shifts in intention to provide CPR.

RESULTS

A total of 428 completed surveys were analysed. When presented with a scenario of being a bystander in an OHCA, a greater proportion of respondents were willing to provide chest-compression-only CPR compared to traditional CPR for all victims (61.5% v. 39.7%, p<0.001), when the victim was a stranger (55.1% v. 38.8%, p<0.001), or when the victim was an unkempt individual (47.9% v. 28.5%, p<0.001). When asked to describe an OHCA, 41.4% said the heart stopped beating, and 20.8% said it was a heart attack. Identified barriers and facilitators included fear of litigation and lack of skill confidence.

CONCLUSIONS

This study identified gaps in knowledge, which may impair the ability of bystanders to act in OHCA. Most respondents expressed greater willingness to provide chest-compression-only CPR, but this was mediated by victim characteristics, skill confidence, and recognition of a cardiac arrest.

Impact of ventilation strategies during chest compression. An experimental study with clinical observations

The optimal ventilation strategy during cardiopulmonary resuscitation (CPR) is unknown. Chest compression (CC) generates circulation, while during decompression, thoracic recoil generates negative pressure and venous return. Continuous flow insufflation of oxygen (CFI) allows noninterrupted CC and generates positive airway pressure (Paw). The main objective of this study was to assess the effects of positive Paw compared with the current recommended ventilation strategy on intrathoracic pressure (P(IT)) variations, ventilation, and lung volume. In a mechanical model, allowing compression of the thorax below an equilibrium volume mimicking functional residual capacity (FRC), CC alone or with manual bag ventilation were compared with two levels of Paw with CFI. Lung volume change below FRC at the end of decompression and P(IT), as well as estimated alveolar ventilation, were measured during the bench study. Recordings were obtained in five cardiac arrest patients to confirm the bench findings. Lung volume was continuously below FRC, and as a consequence P(IT) remained negative during decompression in all situations, including with positive Paw. Compared with manual bag or CC alone, CFI with positive Paw limited the fall in lung volume and resulted in larger positive and negative P(IT) variations. Positive Paw with CFI significantly augmented ventilation induced by CC. Recordings in patients confirmed a major loss of lung volume below FRC during CPR, even with positive Paw. Compared with manual bag ventilation, positive Paw associated with CFI limits the loss in lung volume, enhances CC-induced positive P(IT), maintains negative P(IT) during decompression, and generates more alveolar ventilation.

Survival After Ventricular Fibrillation Cardiac Arrest in the Sao Paulo Metropolitan Subway System: First Successful Targeted Automated External Defibrillator (AED) Program in Latin America

BACKGROUND

Targeted automated external defibrillator (AED) programs have improved survival rates among patients who have an out-of-hospital cardiac arrest (OHCA) in US airports, as well as European and Japanese railways. The Sao Paulo (Brazil) Metro subway carries 4.5 million people per day. A targeted AED program was begun in the Sao Paulo Metro with the objective to improve survival from cardiac arrest.

METHODS AND RESULTS

A prospective, longitudinal, observational study of all cardiac arrests in the Sao Paulo Metro was performed from September 2006 through November 2012. This study focused on cardiac arrest by ventricular arrhythmias, and the primary endpoint was survival to hospital discharge with minimal neurological impairment. A total of 62 patients had an initial cardiac rhythm of ventricular fibrillation. Because no data on cardiac arrest treatment or outcomes existed before beginning this project, the first 16 months of the implementation was used as the initial experience and compared with the subsequent 5 years of full operation. Return of spontaneous circulation was not different between the initial 16 months and the subsequent 5 years (6 of 8 [75%] vs. 39 of 54 [72%]; P=0.88). However, survival to discharge was significantly different once the full program was instituted (0 of 8 vs. 23 of 54 [43%]; P=0.001).

CONCLUSIONS

Implementation of a targeted AED program in the Sao Paulo Metro subway system saved lives. A short interval between arrest and defibrillation was key for good long-term, neurologically intact survival. These results support strategic expansion of targeted AED programs in other large Latin American cities.

Strategy analysis of cardiopulmonary resuscitation training in the community

Bystander cardiopulmonary resuscitation (CPR) is a crucial therapy for sudden cardiac arrest. This appreciation produced immense efforts by professional organizations to train laypeople for CPR skills. However, the rate of CPR training is low and varies widely across communities. Several strategies are used in order to improve the rate of CPR training and are performed in some advanced countries. The Chinese CPR training in communities could gain enlightenment from them.

American Heart Association Response to the 2015 Institute of Medicine Report on Strategies to Improve Cardiac Arrest Survival

The American Heart Association (AHA) commends the recently released Institute of Medicine (IOM) report, Strategies to Improve Cardiac Arrest Survival: A Time to Act (2015). The AHA recognizes the unique opportunity created by the report to meaningfully advance the objectives of improving outcomes for sudden cardiac arrest. For decades, the AHA has focused on the goal of reducing morbidity and mortality from cardiovascular disease though robust support of basic, translational, clinical, and population research. The AHA also has developed a rigorous process using the best available evidence to develop scientific, advisory, and guideline documents. These core activities of development and dissemination of scientific evidence have served as the foundation for a broad range of advocacy initiatives and programs that serve as a foundation for advancing the AHA and IOM goal of improving cardiac arrest outcomes. In response to the call to action in the IOM report, the AHA is announcing 4 new commitments to increase cardiac arrest survival: (1) The AHA will provide up to $5 million in funding over 5 years to incentivize resuscitation data interoperability; (2) the AHA will actively pursue philanthropic support for local and regional implementation opportunities to increase cardiac arrest survival by improving out-of-hospital and in-hospital systems of care; (3) the AHA will actively pursue philanthropic support to launch an AHA resuscitation research network; and (4) the AHA will cosponsor a National Cardiac Arrest Summit to facilitate the creation of a national cardiac arrest collaborative that will unify the field and identify common goals to improve survival. In addition to the AHA’s historic and ongoing commitment to improving cardiac arrest care and outcomes, these new initiatives are responsive to each of the IOM recommendations and demonstrate the AHA’s leadership in the field. However, successful implementation of the IOM recommendations will require a timely response by all stakeholders identified in the report and a coordinated approach to achieve our common goal of improved cardiac arrest outcomes.

Dissemination of Chest Compression–Only Cardiopulmonary Resuscitation and Survival After Out-of-Hospital Cardiac Arrest

Background—

The best cardiopulmonary resuscitation (CPR) technique for survival after out-of-hospital cardiac arrests (OHCAs) has been intensively discussed in the recent few years. However, most analyses focused on comparison at the individual level. How well the dissemination of bystander-initiated chest compression–only CPR (CCCPR) increases survival after OHCAs at the population level remains unclear. We therefore evaluated the impact of nationwide dissemination of bystander-initiated CCCPR on survival after OHCA.

Methods and Results—

A nationwide, prospective, population-based, observational study covering the whole population of Japan and involving consecutive OHCA patients with resuscitation attempts was conducted from January 2005 through December 2012. The main outcome measure was 1-month survival with favorable neurological outcome. The incidence of survival with favorable neurological outcome attributed to types of bystander CPR (CCCPR and conventional CPR with rescue breathing) was estimated. Among 816 385 people experiencing OHCAs before emergency medical services arrival, 249 970 (30.6%) received CCCPR, 100 469 (12.3%) received conventional CPR, and 465 946 (57.1%) received no CPR. The proportion of OHCA patients receiving CCCPR or any CPR (either CCCPR or conventional CPR) by bystanders increased from 17.4% to 39.3% ( P for trend <0.001) and from 34.6% to 47.3% ( P for trend <0.001), respectively. The incidence of survival with favorable neurological outcome attributed to CCCPR per 10 million population significantly increased from 0.6 to 28.3 ( P for trend=0.010), and that by any bystander-initiated CPR significantly increased from 9.0 to 43.6 ( P for trend=0.003).

Conclusion—

Nationwide dissemination of CCCPR for lay-rescuers was associated with the increase in the incidence of survival with favorable neurological outcome after OHCAs in Japan.

Heel compressions quadruple the number of bystanders who can perform chest compressions for 10 minutes

OBJECTIVE

The objective of the study is to evaluate whether chest compressions using the heel provide a more effective method than manual compressions for bystanders.

METHODS

This is a cross-sectional observational comparison study where each subject acted as his or her own control. A 49-person cohort whose age distribution approximated that of sudden cardiac arrest victims were asked to perform 10 minutes of 5-cm manual compressions on a cardiopulmonary resuscitation manikin at 100 compressions per minute. The compression rate and the endurance of each subject were recorded. The same subject was then asked to perform 10 minutes of heel compressions at the same depth and rate.

RESULTS

Sixteen percent of the cohort performed compliant manual compressions for 10 minutes vs 65% using heel compressions. Twenty-four percent of the subjects were not heavy enough to get compliant depth with manual vs 2% with heel compressions, and 6% could not get down on the floor to attempt manual compressions.

DISCUSSION

Most cardiac arrests occur in private residences. If there is a witness, his or her age usually approximates that of the victim. Heel compressions are useful in situations where a lone rescuer cannot get down on the floor, cannot compress the chest to guideline depth because of an infirmity or lack of weight, or becomes too tired to continue manual compressions. Heel compressions significantly increase the bystander population's ability to provide effective, uninterrupted compressions until EMS arrival.

An exploration of attitudes toward bystander cardiopulmonary resuscitation in university students in Tianjin, China: A survey

BACKGROUND

Despite the importance of early effective bystander cardiopulmonary resuscitation (CPR) to improve survival rates from out-of-hospital cardiac arrest, the attitudes toward performing, learning and disseminating CPR in university students of China are still unclear.

METHODS AND AIMS

To assess the attitudes regarding performing, learning and disseminating bystander CPR in university students of China.

RESULTS

The results indicated that except for the scenario where the victim was their own family member or close friend, all other scenarios showed a relatively dismally lower rate of positive response. Besides, it showed a greater willingness to perform chest compression only CPR (CC) than chest compression with mouth-to-mouth ventilation (CCMV) (P < 0.05). Females were more willing to perform CC across seven of the hypothetic scenarios than males. University students of medical-related specialties (45.3%) than university students of non-medical specialties (29.9%) were more willing to perform bystander CPR (P < 0.05). The top four reasons for being unwilling to perform bystander CPR were lack of confidence (32.9%), fear of legal disputes (17.2%), fear of disease transmission (16.0%) and feeling embarrassed (14.0%). 92.6% of respondents wanted to learn CPR and 80.3% of respondents were willing to disseminate CPR.

CONCLUSIONS

CPR technique, victim's status, respondent's specialty and respondent's gender affected the attitudes of respondents toward performing bystander CPR. The top four reasons for being unwilling to perform bystander CPR were lack of confidence, fear of legal disputes, fear of disease transmission and feeling embarrassed. However, the key reason for being unwilling to perform bystander CPR differed in different specialties and particularly 'feeling embarrassment' might be a cultural phenomenon. The attitudes toward learning and disseminating CPR were positive and affected by respondent's gender and specialty.

Cardiac Arrest Resuscitation

Cardiac arrest is a dynamic disease that tests the multitasking and leadership abilities of emergency physicians. Providers must simultaneously manage the logistics of resuscitation while searching for the cause of cardiac arrest. The astute clinician will also realize that he or she is orchestrating only one portion of a larger series of events, each of which directly affects patient outcomes. Resuscitation science is rapidly evolving, and emergency providers must be familiar with the latest evidence and controversies surrounding resuscitative techniques. This article reviews evidence, discusses controversies, and offers strategies to provide quality cardiac arrest resuscitation.

Out-of-hospital cardiac arrest survival improving over time: Results from the Resuscitation Outcomes Consortium (ROC)

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) remains a leading cause of death and a 2010 meta-analysis concluded that outcomes have not improved over several decades. However, guidelines have changed to emphasize CPR quality, minimization of interruptions, and standardized post-resuscitation care. We sought to evaluate whether OHCA outcomes have improved over time among agencies participating in the Resuscitation Outcomes Consortium (ROC) cardiac arrest registry (Epistry) and randomized clinical trials (RCTs).

METHODS

Observational cohort study of 47,148 EMS-treated OHCA cases in Epistry from 139 EMS agencies at 10 ROC sites that participated in at least one RCT between 1/1/2006 and 12/31/2010. We reviewed patient, scene, event characteristics, and outcomes of EMS-treated OHCA over time, including subgroups with initial rhythm of pulseless ventricular tachycardia or ventricular fibrillation (VT/VF).

RESULTS

Mean response interval, median age and male proportion remained similar over time. Unadjusted survival to discharge increased between 2006 and 2010 for treated OHCA (from 8.2% to 10.4%), as well as for subgroups of VT/VF (21.4% to 29.3%) and bystander witnessed VT/VF (23.5% to 30.3%). Compared with 2006, adjusted survival to discharge was significantly higher in 2010 for treated cases (OR = 1.72; 95% CI 1.53, 1.94), VT/VF cases (OR = 1.69; 95% CI 1.45, 1.98) and bystander witnessed VT/VF cases (OR = 1.65; 95% CI 1.36, 2.00). Tests for trend in each subgroup were significant (p < 0.001).

CONCLUSIONS

ROC-wide survival increased significantly between 2006 and 2010. Additional research efforts are warranted to identify specific factors associated with this improvement.

Quality of continuous chest compressions performed for one or two minutes

OBJECTIVES

This study was designed to assess cardiopulmonary resuscitation quality and rescuer fatigue when rescuers perform one or two minutes of continuous chest compressions.

METHODS

This prospective crossover study included 148 lay rescuers who were continuously trained in a cardiopulmonary resuscitation course. The subjects underwent a 120-min training program comprising continuous chest compressions. After the course, half of the volunteers performed one minute of continuous chest compressions, and the others performed two minutes, both on a manikin model. After 30 minutes, the volunteers who had previously performed one minute now performed two minutes on the same manikin and vice versa.

RESULTS

A comparison of continuous chest compressions performed for one and two minutes, respectively, showed that there were significant differences in the average rate of compressions per minute (121 vs. 124), the percentage of compressions of appropriate depth (76% vs. 54%), the average depth (53 vs. 47 mm), and the number of compressions with no errors (62 vs. 47%). No parameters were significantly different when comparing participants who performed regular physical activity with those who did not and participants who had a normal body mass index with overweight/obese participants.

CONCLUSION

The quality of continuous chest compressions by lay rescuers is superior when it is performed for one minute rather than for two minutes, independent of the body mass index or regular physical activity, even if they are continuously trained in cardiopulmonary resuscitation. It is beneficial to rotate rescuers every minute when performing continuous chest compressions to provide higher quality and to achieve greater success in assisting a victim of cardiac arrest.

The Price of a Helping Hand: Modeling the Outcomes and Costs of Bystander CPR

OBJECTIVE

Early, high-quality, minimally interrupted bystander cardio-pulmonary resuscitation (BCPR) is essential for out-of-hospital cardiac arrest survival. However, rates of bystander intervention remain low in many geographic areas. Community CPR programs have been initiated to combat these low numbers by teaching compression-only CPR to laypersons. This study examined bystander CPR and the cost-effectiveness of a countywide CPR program to improve out-of-hospital cardiac arrest survival.

METHODS

A 2-year retrospective review of emergency medical services (EMS) run reports for adult nontraumatic cardiac arrests was performed using existing prehospital EMS quality assurance data. The incidence and success of bystander CPR to produce prehospital return of spontaneous circulation and favorable neurologic outcomes at hospital discharge were analyzed. The outcomes were paired with cost data for the jurisdiction's community CPR program to develop a cost-effectiveness model.

RESULTS

During the 23-month study period, a total of 371 nontraumatic adult out-of-hospital cardiac arrests occurred, with a 33.4% incidence of bystander CPR. Incremental cost-effectiveness analysis for the community CPR program demonstrated a total cost of $22,539 per quality-adjusted life-year (QALY). A significantly increased proportion of those who received BCPR also had an automated external defibrillator (AED) applied. There was no correlation between witnessed arrest and performance of BCPR. A significantly increased proportion of those who received BCPR were found to be in a shockable rhythm when the initial ECG was performed. In the home setting, the chances of receiving BCPR were significantly smaller, whereas in the public setting a nearly equal number of people received and did not receive BCPR. Witnessed arrest, AED application, public location, and shockable rhythm on initial ECG were all significantly associated with positive ROSC and neurologic outcomes. A home arrest was significantly associated with worse neurologic outcome.

CONCLUSIONS

Cost-effectiveness analysis demonstrates that a community CPR outreach program is a cost-effective means for saving lives when compared to other healthcare-related interventions. Bystander CPR showed a clear trend toward improving the neurologic outcome of survivors. The findings of this study indicate a need for additional research into the economic effects of bystander CPR.

Factors affecting layperson confidence in performing resuscitation of out-of-hospital cardiac arrest patients in Japan

Aim

Bystander cardiopulmonary resuscitation including automated external defibrillator use increases the chance of survival after out-of-hospital cardiac arrest. However, bystanders may be distressed by witnessing out-of-hospital cardiac arrest and may hesitate to initiate cardiopulmonary resuscitation. The present study examined factors associated with layperson confidence in carrying out resuscitation of out-of-hospital cardiac arrest patients.

Methods

We carried out a cross-sectional survey in February 2012. Laypeople were asked about background characteristics, whether they had performed cardiopulmonary resuscitation, had received cardiopulmonary resuscitation training, were aware of the location of the neighborhood automated external defibrillator, and felt confident in performing resuscitation, and their potential emotional distress if a resuscitation attempt were to prove unsuccessful.

Results

Participants comprised 4,853 respondents. Of these, 2,372 (49%) had received cardiopulmonary resuscitation training, and 3,607 (74%) knew where the neighborhood automated external defibrillator was located. Confidence in performing chest compressions was reported by 2,667 (55%), confidence in performing rescue breathing by 2,498 (52%), and confidence in using an automated external defibrillator by 2,822 (58%). Potential emotional distress if a resuscitation attempt proved unsuccessful was reported by 4,247 (88%). Multivariate regression analysis showed that having carried out cardiopulmonary resuscitation, having received cardiopulmonary resuscitation training, and awareness of the neighborhood automated external defibrillator location were significantly associated with confidence in performing cardiopulmonary resuscitation.

Conclusions

Our results suggest that more extensive cardiopulmonary resuscitation training and information regarding neighborhood automated external defibrillator locations may increase layperson confidence in initiating resuscitation.

Comparison of CPR quality and rescuer fatigue between standard 30:2 CPR and chest compression-only CPR: a randomized crossover manikin trial

Objective

We aimed to compare rescuer fatigue and cardiopulmonary resuscitation (CPR) quality between standard 30:2 CPR (ST-CPR) and chest compression only CPR (CO-CPR) performed for 8 minutes on a realistic manikin by following the 2010 CPR guidelines.

Methods

All 36 volunteers (laypersons; 18 men and 18 women) were randomized to ST-CPR or CO-CPR at first, and then each CPR technique was performed for 8 minutes with a 3-hour rest interval. We measured the mean blood pressure (MBP) of the volunteers before and after performing each CPR technique, and continuously monitored the heart rate (HR) of the volunteers during each CPR technique using the MRx monitor. CPR quality measures included the depth of chest compression (CC) and the number of adequate CCs per minute.

Results

The adequate CC rate significantly differed between the 2 groups after 2 minutes, with it being higher in the ST-CPR group than in the CO-CPR group. Additionally, the adequate CC rate significantly differed between the 2 groups during 8 minutes for male volunteers (p =0.012). The number of adequate CCs was higher in the ST-CPR group than in the CO-CPR group after 3 minutes (p =0.001). The change in MBP before and after performing CPR did not differ between the 2 groups. However, the change in HR during 8 minutes of CPR was higher in the CO-CPR group than in the ST-CPR group (p =0.007).

Conclusions

The rate and number of adequate CCs were significantly lower with the CO-CPR than with the ST-CPR after 2 and 6 minutes, respectively, and performer fatigue was higher with the CO-CPR than with the ST-CPR during 8 minutes of CPR.

Cardiocerebral Resuscitation: An Approach to Improving Survival of Patients With Primary Cardiac Arrest

Out-of-hospital cardiac arrest (OHCA) is a major public health problem. In the United States, OHCA accounts for more premature deaths than any other cause. For over a half-century, the national "Guidelines" for resuscitation have recommended the same initial treatment of primary and secondary cardiac arrests. Using this approach, the overall survival of patients with OHCA, while quite variable, was generally very poor. One reason is that the etiologies of cardiac arrests are not all the same. The vast majority of nontraumatic OHCA in adults are due to a "primary" cardiac arrest, rather than secondary to respiratory arrest. Decades of research and ongoing reviews of the literature led the University of Arizona Sarver Heart Center Resuscitation Research Group to conclude in 2003 that the national guidelines for patients with primary cardiac arrest were not optimal. Therefore, we instituted a new, nonguidelines approach to the therapy of primary cardiac arrest that dramatically improved survival. We called this approach cardiocerebral resuscitation (CCR), as it is the heart and the brain that are the most vulnerable and therefore need to be the focus of resuscitation efforts for these patients. In contrast, cardiopulmonary resuscitation should be reserved for respiratory arrests. Cardiocerebral resuscitation evolved into 3 components: the community, with emphasis for lay individuals to "Check, Call, Compress" and use an automated external defibrillator if available; the Emergency Medical Services, that emphasizes delayed intubation in favor of passive ventilation, urgent and near continuous chest compressions before and immediately after a single indicated shock, and the early administration of epinephrine; and the third component, added in 2007, the designations of hospitals in Arizona that request this designation and agree to receive patients with return of spontaneous circulation following OHCA and to institute state-of-the-art postresuscitation care that includes urgent therapeutic mild hypothermia and cardiac catheterization as a Cardiac Receiving Center. Each component of CCR is critical for optimal survival of patients with primary OHCA. In each city, county, and state where CCR was instituted, the result was a marked increase in survival of the subgroup of patients with OHCA most likely to survive, for example, those with a shockable rhythm. The purpose of this invited article on CCR is to review this alternative approach to resuscitation of patients with primary cardiac arrest and to encourage its adoption worldwide so that more lives can be saved.

Disparities in bystander CPR provision and survival from out-of-hospital cardiac arrest according to neighborhood ethnicity

STUDY OBJECTIVE

We aimed to determine if there are differences in bystander cardiopulmonary resuscitation (BCPR) provision and survival to hospital discharge from out-of-hospital cardiac arrest (OHCA) occurring in Hispanic neighborhoods in Arizona.

METHODS

We analyzed a prospectively collected, statewide Utstein-compliant OHCA database between January 1, 2010, and December 31, 2012. Cases of OHCA were geocoded to determine their census tract of event location, and their neighborhood main ethnicity was assigned using census data. Neighborhoods were classified as "Hispanic" or "non-Hispanic white" when the percentage of residents in the census tract was 80% or more.

RESULTS

Among the 6637 geocoded adult OHCA victims during the study period, 4821 cases were included in this analysis, after excluding 1816 cases due to incident location, traumatic cause, or because the arrest occurred after emergency medical service arrival. In OHCAs occurring at Hispanic neighborhoods as compared with non-Hispanic white neighborhoods, the provision of BCPR (28.6% vs 43.8%; P < .001) and initially monitored shockable rhythm (17.3% vs 25.7%; P < .006) was significantly less frequent. Survival to hospital discharge was significantly lower in Hispanic neighborhoods than in non-Hispanic white neighborhoods (4.9% vs 10.8%; P = .013). The adjusted odds ratio (OR) of Hispanic neighborhood for BCPR provision (OR, 0.62; 95% confidence interval, 0.44-0.89) was lower as compared with non-Hispanic white neighborhoods.

CONCLUSIONS

In Arizona, OHCA patients in Hispanic neighborhoods received BCPR less frequently and had a lower survival to hospital discharge rate than those in non-Hispanic white neighborhoods. Public health efforts to attenuate this disparity are needed.

Additional responsibility for physicians caring for cardiac patients: Insight from a case series

Resuscitation measures performed at the scene of the event have the ultimate impact on the outcome of a cardiac arrest. We analysed six case histories of those sudden cardiac arrest patients who were revived in the field and were subsequently admitted to the intensive care unit during a six-month period. All were known cardiac patients and were under the care of healthcare providers. Four of those were discharged home from the hospital and did not suffer any residual damage where as one died of multi-organ failure and the other was declared brain dead. The outcome was good in patients who received early intervention in the form of basic life support. The family members of non-survivors witnessed the cardiac arrest at home but were not familiar with the concept or procedures of basic life support. We propose that physicians who care for cardiac patients should undertake the task of increasing family member awareness and knowledge in the techniques of basic life support.

Long-term retention of cardiopulmonary resuscitation skills after shortened chest compression-only training and conventional training: a randomized controlled trial

OBJECTIVES

It is unclear how much the length of a cardiopulmonary resuscitation (CPR) training program can be reduced without ruining its effectiveness. The authors aimed to compare CPR skills 6 months and 1 year after training between shortened chest compression-only CPR training and conventional CPR training.

METHODS

Participants were randomly assigned to either the compression-only CPR group, which underwent a 45-minute training program consisting of chest compressions and automated external defibrillator (AED) use with personal training manikins, or the conventional CPR group, which underwent a 180-minute training program with chest compressions, rescue breathing, and AED use. Participants' resuscitation skills were evaluated 6 months and 1 year after the training. The primary outcome measure was the proportion of appropriate chest compressions 1 year after the training.

RESULTS

A total of 146 persons were enrolled, and 63 (87.5%) in the compression-only CPR group and 56 (75.7%) in the conventional CPR group completed the 1-year evaluation. The compression-only CPR group was superior to the conventional CPR group regarding the proportion of appropriate chest compression (mean ± SD = 59.8% ± 40.0% vs. 46.3% ± 28.6%; p = 0.036) and the number of appropriate chest compressions (mean ± SD = 119.5 ± 80.0 vs. 77.2 ± 47.8; p = 0.001). Time without chest compression in the compression-only CPR group was significantly shorter than that in the conventional CPR group (mean ± SD = 11.8 ± 21.1 seconds vs. 52.9 ± 14.9 seconds; p < 0.001).

CONCLUSIONS

The shortened compression-only CPR training program appears to help the general public retain CPR skills better than the conventional CPR training program.

CLINICAL TRIAL REGISTRATION

UMIN-CTR UMIN000001675.

Advances in prehospital airway management

Prehospital airway management is a key component of emergency responders and remains an important task of Emergency Medical Service (EMS) systems worldwide. The most advanced airway management techniques involving placement of oropharyngeal airways such as the Laryngeal Mask Airway or endotracheal tube. Endotracheal tube placement success is a common measure of out-of-hospital airway management quality. Regional variation in regard to training, education, and procedural exposure may be the major contributor to the findings in success and patient outcome. In studies demonstrating poor outcomes related to prehospital-attempted endotracheal intubation (ETI), both training and skill level of the provider are usually often low. Research supports a relationship between the number of intubation experiences and ETI success. National standards for certification of emergency medicine provider are in general too low to guarantee good success rate in emergency airway management by paramedics and physicians. Some paramedic training programs require more intense airway training above the national standard and some EMS systems in Europe staff their system with anesthesia providers instead. ETI remains the cornerstone of definitive prehospital airway management, However, ETI is not without risk and outcomes data remains controversial. Many systems may benefit from more input and guidance by the anesthesia department, which have higher volumes of airway management procedures and extensive training and experience not just with training of airway management but also with different airway management techniques and adjuncts.

Continuous chest compression pediatric cardiopulmonary resuscitation after witnessed electrocution

Electrical injury is a relatively infrequent but potentially devastating multisystem injury with high morbidity and mortality. We describe the case of an 11-year-old boy who suffered loss of his consciousness after touching an electrical cable.

"Push as hard as you can" instruction for telephone cardiopulmonary resuscitation: a randomized simulation study

BACKGROUND

The medical priority dispatch system (MPDS®) assists lay rescuers in protocol-driven telephone-assisted cardiopulmonary resuscitation (CPR).

OBJECTIVE

Our aim was to clarify which CPR instruction leads to sufficient compression depth.

METHODS

This was an investigator-blinded, randomized, parallel group, simulation study to investigate 10 min of chest compressions after the instruction "push down firmly 5 cm" vs. "push as hard as you can." Primary outcome was defined as compression depth. Secondary outcomes were participants exertion measured by Borg scale, provider's systolic and diastolic blood pressure, and quality values measured by the skill-reporting program of the Resusci(®) Anne Simulator manikin. For the analysis of the primary outcome, we used a linear random intercept model to allow for the repeated measurements with the intervention as a covariate.

RESULTS

Thirteen participants were allocated to control and intervention. One participant (intervention) dropped out after min 7 because of exhaustion. Primary outcome showed a mean compression depth of 44.1 mm, with an inter-individual standard deviation (SDb) of 13.0 mm and an intra-individual standard deviation (SDw) of 6.7 mm for the control group vs. 46.1 mm and a SDb of 9.0 mm and SDw of 10.3 mm for the intervention group (difference: 1.9; 95% confidence interval -6.9 to 10.8; p = 0.66). Secondary outcomes showed no difference for exhaustion and CPR-quality values.

CONCLUSIONS

There is no difference in compression depth, quality of CPR, or physical strain on lay rescuers using the initial instruction "push as hard as you can" vs. the standard MPDS(®) instruction "push down firmly 5 cm."

Availability and quality of cardiopulmonary resuscitation information for Spanish-speaking population on the Internet

BACKGROUND

Bystander cardiopulmonary resuscitation (CPR) is a vital link in the chain of survival for out-of-hospital cardiac arrest (OHCA); however, there are racial/ethnic disparities in the provision of bystander CPR. Approximately 32% of Hispanics perform CPR when confronted with cardiac arrest, whereas approximately 41% of non-Hispanics perform CPR. Public education, via the Internet, may be critical in improving the performance of bystander CPR among Hispanics. The objective of this study was to evaluate the availability and quality of CPR-related literature for primary Spanish-speaking individuals on the Internet.

METHODS

Two search engines (Google and Yahoo!) and a video-site (YouTube) were searched using the following terms: "resucitacion cardiopulmonar" and "reanimacion cardiopulmonar." Inclusion criteria were: education of CPR technique. Exclusion criteria were: instruction on pediatric CPR technique, failure to provide any instruction on CPR technique, or duplicated website. Data elements were collected on the content and quality of the websites and videos, such as assessing scene safety, verifying responsiveness, activating EMS, properly positioning hands on chest, performing accurate rate and depth of compressions.

RESULTS

Of the 515 websites or videos screened, 116 met criteria for inclusion. The majority of websites (86%; 95% Confidence Interval [CI] 79-92%) educated viewers on traditional bystander CPR (primarily, 30:2 CPR), while only 14% (95% CI 9-21%) taught hands-only CPR. Of websites that used video (N=62), 84% were conducted in Spanish and 16% in English. The quality of CPR education was generally poor (median score of 3/6, IQR of 3.0). Only half of websites properly educated on how to check responsiveness, activate EMS and position hands on chest. Eighty-eight percent of websites failed to educate viewers on assessing scene safety. The majority of websites had improper or no education on both rate and depth of compressions (59% and 63%, respectively). Only 16% of websites included 5 or more quality markers for proper bystander CPR.

CONCLUSIONS

A small proportion of internet resources have high quality CPR education for a Spanish-speaking population. More emphasis should be placed on improving the quality of educational resources available on the Internet for Spanish-speaking populations, and with particular emphasis on current basic life support recommendations.

Barriers and facilitators to learning and performing cardiopulmonary resuscitation in neighborhoods with low bystander cardiopulmonary resuscitation prevalence and high rates of cardiac arrest in Columbus, OH

BACKGROUND

Residents who live in neighborhoods that are primarily black, Latino, or poor are more likely to have an out-of-hospital cardiac arrest, less likely to receive cardiopulmonary resuscitation (CPR), and less likely to survive. No prior studies have been conducted to understand the contributing factors that may decrease the likelihood of residents learning and performing CPR in these neighborhoods. The goal of this study was to identify barriers and facilitators to learning and performing CPR in 3 low-income, high-risk, and predominantly black neighborhoods in Columbus, OH.

METHODS AND RESULTS

Community-Based Participatory Research approaches were used to develop and conduct 6 focus groups in conjunction with community partners in 3 target high-risk neighborhoods in Columbus, OH, in January to February 2011. Snowball and purposeful sampling, done by community liaisons, was used to recruit participants. Three reviewers analyzed the data in an iterative process to identify recurrent and unifying themes. Three major barriers to learning CPR were identified and included financial, informational, and motivational factors. Four major barriers were identified for performing CPR and included fear of legal consequences, emotional issues, knowledge, and situational concerns. Participants suggested that family/self-preservation, emotional, and economic factors may serve as potential facilitators in increasing the provision of bystander CPR.

CONCLUSIONS

The financial cost of CPR training, lack of information, and the fear of risking one's own life must be addressed when designing a community-based CPR educational program. Using data from the community can facilitate improved design and implementation of CPR programs.

Japanese Circulation Society Resuscitation Science Study Group. Chest-compression-only bystander cardiopulmonary resuscitation in the 30:2 compression-to-ventilation ratio era. Nationwide observational study

BACKGROUND

The compression-to-ventilation ratio for basic cardiopulmonary resuscitation (CPR) was changed from 15:2 to 30:2, but there are few human studies comparing chest-compression-only CPR with standard CPR.

METHODS AND RESULTS

From the All-Japan Utstein Registry in the 30:2 CPR era, 173,565 adult cardiac arrests witnessed by bystanders were included. On arrival at the scene, emergency medical services responders assessed the status of dispatcher-assisted CPR instruction and bystander CPR technique (chest compression with or without rescue breathing). The primary endpoint was favorable neurological outcome 30 days after cardiac arrest. The prevalence of dispatcher-assisted CPR instruction increased year by year, contributing to an overall increase of chest-compression-only bystander CPR from 20.6% to 35.0%. Among 78,150 patients receiving bystander CPR, favorable neurological outcome did not differ between dispatcher-assisted and -unassisted CPR (adjusted odds ratio [OR], 1.00; 95% confidence interval [CI]: 0.94-1.08). Chest-compression-only CPR resulted in better favorable neurological outcome than standard CPR in the whole cohort (adjusted OR, 1.09; 95% CI: 1.00-1.18) and in the subgroup with cardiac etiology (adjusted OR, 1.12; 95% CI: 1.02-1.22). The addition of rescue breathing provided no neurological benefit in the non-cardiac etiology subgroup.

CONCLUSIONS

In the 30:2 CPR era, dispatcher-assisted CPR instruction contributed to an increase of chest-compression-only bystander CPR, supporting the use of chest-compression-only CPR for bystander-witnessed out-of-hospital cardiac arrest in all adults.

Current knowledge of and willingness to perform Hands-Only CPR in laypersons

INTRODUCTION

Recent simplified guidelines recommend Hands-Only CPR for laypersons and efforts to educate the public of these changes have been made. We determined current knowledge of and willingness to perform Hands-Only CPR.

METHODS

Design-prospective anonymous survey. Setting-academic suburban emergency department. Subjects-adult patients and visitors in a suburban ED. Survey instrument-33 item closed question format based on prior studies that included baseline demographics and knowledge and experience of CPR. Main outcome-knowledge of and willingness to perform Hands-Only CPR. Data analysis-descriptive statistics. Univariate and multivariate analyses were performed to determine the association between predictor variables and knowledge of and willingness to perform Hands-Only CPR.

RESULTS

We surveyed 532 subjects; mean age was 44±16; 53.2% were female, 75.6% were white. 45.5% were college graduates, and 44.4% had an annual income of greater than $50,000. 41.9% had received prior CPR training; only 10.3% had performed CPR. Of all subjects 124 (23.3%) had knowledge of Hands-Only CPR, yet 414 (77.8%) would be willing to perform Hands-Only CPR on a stranger. Age (P=0.003) and income (P=0.014) predicted knowledge of Hands-Only CPR. A history of a cardiac related event in the family (P=0.003) and previous CPR training (P=0.01) were associated with likelihood to perform Hands-Only CPR.

CONCLUSIONS

Less than one fifth of surveyed laypersons knew of Hands-Only CPR yet three quarters would be willing to perform Hands-Only CPR even on a stranger. Efforts to increase layperson education are required to enhance CPR performance.

Push hard, push fast, if you're downtown: a citation review of urban-centrism in American and European basic life support guidelines

Bystander cardiopulmonary resuscitation (CPR) improves out-of-hospital cardiac arrest (OHCA) survival. In settings with prolonged ambulance response times, skilled bystanders may be even more crucial. In 2010, American Heart Association (AHA) and European Resuscitation Council (ERC) introduced compression-only CPR as an alternative to conventional bystander CPR under some circumstances. The purpose of this citation review and document analysis is to determine whether the evidentiary basis for 2010 AHA and ERC guidelines attends to settings with prolonged ambulance response times or no formal ambulance dispatch services. Primary and secondary citations referring to epidemiological research comparing adult OHCA survival based on the type of bystander CPR were included in the analysis. Details extracted from the citations included a study description and primary outcome measure, the geographic location in which the study occurred, EMS response times, the role of dispatchers, and main findings and summary statistics regarding rates of survival among patients receiving no CPR, conventional CPR or compression-only CPR. The inclusion criteria were met by 10 studies. 9 studies took place exclusively in urban settings. Ambulance dispatchers played an integral role in 7 studies. The cited studies suggest either no survival benefit or harm arising from compression-only CPR in settings with extended ambulance response times. The evidentiary basis for 2010 AHA and ERC bystander CPR guidelines does not attend to settings without rapid ambulance response times or dispatch services. Standardized bystander CPR guidelines may require adaptation or reconsideration in these settings.

Duration of Ventilations During Cardiopulmonary Resuscitation by Lay Rescuers and First Responders

Background—

The 2010 guidelines for cardiopulmonary resuscitation allow 5 seconds to give 2 breaths to deliver sufficient chest compressions and to keep perfusion pressure high. This study aims to determine whether the recommended short interruption for ventilations by trained lay rescuers and first responders can be achieved and to evaluate its consequence for chest compressions and survival.

Methods and Results—

From a prospective data collection of out-of-hospital cardiac arrest, we used automatic external defibrillator recordings of cardiopulmonary resuscitation by rescuers who had received a standard European Resuscitation Council basic life support and automatic external defibrillator course. Ventilation periods and total compressions delivered per minute during each 2 minutes of cardiopulmonary resuscitation cycle were measured, and the chest compression fraction was calculated. Neurological intact survival to discharge was studied in relation to these factors and covariates. We included 199 automatic external defibrillator recordings. The median interruption time for 2 ventilations was 7 seconds (25th–75th percentile, 6–9 seconds). Of all rescuers, 21% took <5 seconds and 83% took <10 seconds for a ventilation period; 97%, 88%, and 63% of rescuers were able to deliver >60, >70, and >80 chest compressions per minute, respectively. The median chest compression fraction was 65% (25th–75th percentile, 59%–71%). Survival was 25% (49 of 199), not associated with long or short ventilation pauses when controlled for covariates.

Conclusions—

The great majority of rescuers can give 2 rescue breaths in <10 seconds and deliver at least 70 compressions in a minute. Longer pauses for ventilations are not associated with worse outcome. Guidelines may allow longer pauses for ventilations with no detriment to survival.

Chest compression-only cardiopulmonary resuscitation for out-of-hospital cardiac arrest with public-access defibrillation: a nationwide cohort study

BACKGROUND

It remains unclear which is more effective to increase survival after out-of-hospital cardiac arrest in those with public-access defibrillation, bystander-initiated chest compression-only cardiopulmonary resuscitation (CPR) or conventional CPR with rescue breathing.

METHODS AND RESULTS

A nationwide, prospective, population-based observational study covering the whole population of Japan and involving consecutive out-of-hospital cardiac arrest patients with resuscitation attempts has been conducted since 2005. We enrolled all out-of-hospital cardiac arrests of presumed cardiac origin that were witnessed and received shocks with public-access automated external defibrillation (AEDs) by bystanders from January 1, 2005, to December 31, 2009. The main outcome measure was neurologically favorable 1-month survival. We compared outcomes by type of bystander-initiated CPR (chest compression-only CPR and conventional CPR with compressions and rescue breathing). Multivariable logistic regression was used to assess the relationship between the type of CPR and a better neurological outcome. During the 5 years, 1376 bystander-witnessed out-of-hospital cardiac arrests of cardiac origin in individuals who received CPR and shocks with public-access AEDs by bystanders were registered. Among them, 506 (36.8%) received chest compression-only CPR and 870 (63.2%) received conventional CPR. The chest compression-only CPR group (40.7%, 206 of 506) had a significantly higher rate of 1-month survival with favorable neurological outcome than the conventional CPR group (32.9%, 286 of 870; adjusted odds ratio, 1.33; 95% confidence interval, 1.03-1.70).

CONCLUSIONS

Compression-only CPR is more effective than conventional CPR for patients in whom out-of-hospital cardiac arrest is witnessed and shocked with public-access defibrillation. Compression-only CPR is the most likely scenario in which lay rescuers can witness a sudden collapse and use public-access AEDs.

Critical cardiovascular skills and procedures in the emergency department

The management of cardiovascular emergencies is a fundamental component of the practice of an emergency practitioner. Delays in the evaluations and management can lead to significant morbidity or mortality. It is of vital importance to be familiar with procedures such as pericardiocentesis, cardioversion, defibrillation, temporary pacing, and options for the management of tachyarrhythmias. This article discusses the most common cardiovascular procedures encountered in an emergency setting, including the indications, contraindications, equipment, technique, and complications for each procedure.

Chest Compression Alone Cardiopulmonary Resuscitation Is Associated With Better Long-Term Survival Compared with Standard Cardiopulmonary Resuscitation

Background—

Little is known about the long-term survival effects of type-specific bystander cardiopulmonary resuscitation (CPR) in the community. We hypothesized that dispatcher instruction consisting of chest compression alone would be associated with better overall long-term prognosis in comparison with chest compression plus rescue breathing.

Methods and Results—

The investigation was a retrospective cohort study that combined 2 randomized trials comparing the short-term survival effects of dispatcher CPR instruction consisting either of chest compression alone or chest compression plus rescue breathing. Long-term vital status was ascertained by using the respective National and State death records through July 31, 2011. We performed Kaplan-Meier method and Cox regression to evaluate survival according to the type of CPR instruction. Of the 2496 subjects included in the current investigation, 1243 (50%) were randomly assigned to chest compression alone and 1253 (50%) were randomly assigned to chest compression plus rescue breathing. Baseline characteristics were similar between the 2 CPR groups. During the 1153.2 person-years of follow-up, there were 2260 deaths and 236 long-term survivors. Randomization to chest compression alone in comparison with chest compression plus rescue breathing was associated with a lower risk of death after adjustment for potential confounders (adjusted hazard ratio, 0.91; 95% confidence interval, 0.83–0.99; P =0.02).

Conclusions—

The findings provide strong support for long-term mortality benefit of dispatcher CPR instruction strategy consisting of chest compression alone rather than chest compression plus rescue breathing among adult patients with cardiac arrest requiring dispatcher assistance.

Evaluation of Chest Compression Depth during Nine Minutes of Hands-Only Cardiopulmonary Resuscitation Performed by a Lone Rescuer and its Effect by Age Group: A Pilot Simulation Study Using a Manikin

Objective

There have been few studies on the use of long-standing hands-only cardiopulmonary resuscitation (CPR) by a lone rescuer. This study aimed to evaluate the long-standing (nine minutes) hands-only CPR by a lone rescuer, and the change of chest compression depth over time. The effect of age of rescuer on chest compression depth was also studied.

Methods

From a total of 404 adult lay-persons who participated in CPR training, 91 subjects were enrolled in the simulation trial of nine minutes of hands-only CPR using a manikin with a Skill-Reporter™. The quality of the chest compression over time and the effects of rescuer age were analysed.

Results

Of the 91 participants, 74 (81%) fully completed the nine minutes of CPR. No significant differences of incomplete CPR rate between each age group were observed. No significant differences in the degree of reduction in effective chest compressions were observed based on the time course among the different age groups. The total number of compressions decreased abruptly from the six-minute time point onwards (five minutes vs. six minutes, p=0.038).

Conclusions

Most trained lay-persons could complete the 9 minutes of hands-only CPR. The rate of chest compression shows a significant decrease after 6 minute. We do not find a significant difference in the decrease of adequate chest compressions over time among various age groups in this pilot simulation study.