Understanding the Importance of the Lay Responder Experience in Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association

"I can't unsee him lying in my kitchen": Understanding the trauma of family members who witness a loved one's cardiac arrest

Background

While there is a growing body of research in the field of post-cardiac arrest outcomes and survivorship, the lived experience of close family members who witness the arrest itself and who may have performed CPR, has not been specifically explored.

Methods

We employed qualitative interpretive descriptive methodology using key informant interviews for data collection. Participants were recruited internationally, and interviews were conducted virtually following a semi-structured format. Thematic data analysis was conducted using a constant comparative approach.

Results

Interviews were conducted with 33 family members who were present at the time of their loved ones cardiac arrest. Across the participant stories, we identified the core concept of 'base trauma' that centres around what family member witnesses initially experience at the time of the arrest itself. We postulate that this core theme influences six significant patterns of experience including: 1) feelings of responsibility, 2) fear of recurrence without them, 3) the impact of reliving the event, 4) the inability to escape triggers, 5) the delayed realization of their own trauma, and lastly 6) dealing with psychologic disconnect.

Conclusions

There is increasing research evidence that family members of cardiac arrest survivors have their own challenges as part of the recovery journey. We introduce novel concept of the compounded impact of the initial base trauma those that witness and respond to a loved ones cardiac arrest have. The nuanced experiences of this group point to the need to normalize their experience as a 'trauma' and suggest that support pathways need to recognize this.

FirstCPR: A pragmatic community organisation-based cluster randomised trial to increase community training and preparedness to respond to out-of-hospital cardiac arrest

Background

Bystander cardiopulmonary resuscitation (CPR) and defibrillation improve out-of-hospital cardiac arrest survival. However, basic life support (BLS) skills are low.

Aim

The FirstCPR cluster randomised controlled trial aimed to test the effectiveness of a community organisation-targeted BLS education and training approach.

Methods

Clusters (community organisations with 50+ members) were randomly allocated to intervention (12-month period of opportunities to access BLS education and training) or control (no intervention). Outcomes were assessed via surveys at 12 months and pre-specified analysis involved hierarchical mixed-models.

Results

Of 165 randomised clusters (82 intervention), 58% were sports and 42% were social/faith-based. Most of the intervention clusters (74/82) participated in at least one intervention activity (15 in all activities). Factors such as the COVID-19 pandemic and organisation support impacted intervention uptake. Overall 924 members, across 93 clusters (407 from 57 intervention clusters; 517 from 36 control clusters), completed surveys. At 12-months, intervention organisation surveyed members reported higher rates of: being trained and willing to perform CPR on a stranger (primary outcome: 63.8% vs 46.9 %; Adjusted Odds Ratio (AOR) 2.22, 95% confidence interval (CI):1.50-3.30), confidence to use an automated external defibrillator (AED) (48.4% vs 26.4%; AOR:3.23, 95%CI:2.22-4.71) and willingness to use AEDs on a stranger (73.9% vs 62.9%; AOR:1.84, 95%CI:1.22-2.80).

Conclusions

The results should be interpreted cautiously as the survey response rates were very low. However, survey respondents showed desired outcomes and key learnings for future research were gained.

Psychological impact on first responders dispatched to out-of-hospital cardiac arrest via smartphone alerting system: A longitudinal survey-based study

Background

Smartphone alerting systems designed to dispatch volunteer first responders to out-of-hospital cardiac arrest cases are progressing rapidly. Recently, growing attention has been given to understanding the impact of these operations on first responders, with a particular focus on safeguarding them from possible psychological challenges. This study investigates the psychological stress experienced by first responders following their involvement in an operation, analyzing specific stress factors to enhance opportunities for psychological support.

Methods

A two-stage questionnaire (Q1 and Q2) survey was conducted, with surveys administered one and four weeks after dispatched first responder arrived at the scene between October 9, 2023, and January 23, 2024. Screening questions based on the FAUST study assessed psychological stress, with ≥4 positive responses indicating at-risk individuals. Personal and operational variables were analyzed for their correlation with stress levels for identifying affected first responder. The study was approved by the Freiburg Ethics Committee (DRKS00032958).

Results

The response rates for the triggered questionnaires were 190/324 (59%) for Q1 and 132/322 (41%) for Q2. Fewer than 1% answered ≥4 screening questions positively, indicating a low measured prevalence of psychological stress. Situations involving resuscitation or already deceased patients but also first responders' feelings of insecurity were identified as significant factors of possible psychological stress, while regular CPR training appeared to significantly reduce the likelihood of stress.

Conclusions

First responders who volunteer for such roles frequently encounter challenging situations. However, psychological stress is rarely reported. Integrating mechanisms into smartphone alerting systems to identify stress indicators and provide accessible support is essential.

Resuscitation education science meets virtual and augmented reality: Evolution from potential concept to recommendations

Aim of the study

This study aims to examine the evolution of recommendations for integrating Virtual Reality (VR) and Augmented Reality (AR) into adult Basic Life Support (BLS) education over time.

Data sources

In December 2024, we conducted a two-phase search. First, we identified and reviewed publications available on the International Liaison Committee on Resuscitation (ILCOR) webpage, focusing on resuscitation education science, specifically addressing VR and/or AR in adult BLS education. In the second phase, we reviewed the references and citations of the included publication to identify relevant publications from the American Heart Association (AHA), European Resuscitation Council (ERC), and ILCOR.

Results

Across both phases, we included 29 AHA, ERC, and ILCOR publications on resuscitation education. These comprised 16 ILCOR CoSTRs, seven AHA/ERC guidelines (four ERC, three AHA), three ILCOR scientific statements, two AHA scientific statements, and one ILCOR review. The first mention of VR appeared in 2003, but the first recommendation was provided in 2020 AHA guidelines, suggesting its use for adult BLS training based on very low-quality evidence. In 2024, the ILCOR CoSTRs issued a weak recommendation supporting AR and a weak recommendation against VR for adult BLS training, both based on very low-quality evidence.

Conclusion

While VR/AR is gaining traction in resuscitation training, its effectiveness remains debated. Initially focused on professionals, it now extends to laypersons and schoolchildren. However, strong evidence is lacking. Future research should assess learning outcomes, guideline adherence, and patient impact to support stronger ILCOR recommendations.

Saving lives together in sport: - A pilot study attempting to increase the number and availability of automated external defibrillators and to initiate voluntary training in cardiopulmonary resuscitation with the use of automated external defibrillators in Norwegian amateur football clubs

OBJECTIVES

In Norway, the potential to increase the number of patients connected to an automated external defibrillator (AED) before ambulance arrival in out-of-hospital cardiac arrests is substantial. A blended learning approach is effective for cardiopulmonary resuscitation (CPR) training with AED usage, and regular hands-on CPR refresher training is recommended. The objective was to test if provision of CPR-training equipment and learning resources combined with a contract to recruit volunteer CPR trainers could facilitate regular refresher CPR-training in Norwegian football clubs and to increase the number and accessibility of AEDs by providing clubs with AEDs and heated cabinets and mandate registration in the national AED registry.

METHODS

Non-randomized pilot study (2020-2023). Clubs signed contracts that they would perform CPR training with the use of AEDs for 70% of football players/coaches/staff/volunteers each year and place their received AED outdoors in heated cabinets and register their AED in the Norwegian national AED registry. We explored barriers through follow-up e-mails.

RESULTS

We recruited 116 of 278 (42%) eligible football clubs. From 2020 to 2023, 5440 football players and 987 coaches/staff/volunteers from 60 (52%) clubs completed CPR training sessions and 20 (17%) repeated CPR training. We provided 112 AEDs and 116 heated cabinets. By a deadline, 68/116 (59%) of clubs had placed their AED outdoors in the heated cabinet and registered their AED correctly in the national AED registry, 27/116 (23%) placed their AED outdoors but did not complete their registration in the AED registry correctly, 13/116 (11%) kept their AED locked indoors and 8/116 (7%) failed to register their AED. Few clubs (20/116, 17%) provided insights into barriers.

CONCLUSION

We recruited a satisfactory number of football clubs. Over 6000 players/coaches/staff/volunteers completing CRP training shows promise. Most clubs complied to the message of 24/7/365 availability of AEDs and found registration in the national AED registry uncomplicated.

Public participation willingness in out-of-hospital cardiopulmonary resuscitation: A systematic review and meta-analysis

Objective

This systematic review and meta-analysis aimed to identify the main factors influencing the public's willingness to participate in out-of-hospital emergency care.

Methods

Studies were searched in online databases, including PubMed, Embase, Web of Science, and the Cochrane Library. The articles included in this review were published from inception to July 31, 2024. The Iain Crombie assessment tool was used to assess study quality. Meta-analysis was performed using RevMan (version 5.4) software. The review protocol has been registered with PROSPERO (CRD42024570491).

Results

A total of 1,434 research articles were initially identified, among which 18 were incorporated into this study, and all of the included studies were cross-sectional. Meta-analysis results demonstrated that gender (male; OR = 1.37, 95%CI: 1.28-1.47), profession (healthcare provider; OR = 0.17, 95%CI: 0.06-0.47), knowledge and skill level (OR = 1.63, 95%CI: 1.25-2.11), willingness to undergo training (OR = 2.68, 95%CI: 1.89-3.79), interest in first aid (OR = 2.08, 95%CI: 1.60-2.69), previous training (OR = 2.14, 95%CI: 1.49-3.08), and previous first-aid experience (OR = 1.70, 95%CI: 1.37-2.11) were the principal influencing factors of the public's willingness to engage in out-of-hospital cardiopulmonary resuscitation.

Conclusion

Demographic factors, knowledge, belief, and behavior are crucial in influencing public emergency decision-making. Medical personnel could create specialized training programs based on relevant factors to enhance the public's willingness to engage in out-of-hospital CPR.

Association between bystander cardiopulmonary resuscitation initiation and patient's sex: a systematic review and meta-analysis

Background and aim

The chain of survival, including cardiopulmonary resuscitation (CPR) and automated external defibrillation (AED), improves patients' outcomes in case of cardiac arrest. Socioeconomic status, race, and gender appear to be associated with the likelihood of receiving resuscitation. The aim of this systematic review and meta-analysis was to evaluate the association between female sex and the odds of bystander CPR initiation and AED application in patients with cardiac arrest, compared with male individuals.

Methods

The protocol of this systematic review was prospectively registered in PROSPERO (CRD42024512024). PubMed, Scopus, and Cochrane were searched for studies describing the association between patient sex and the initiation of bystander CPR or the application of AED pads.

Results

Fifteen observational cohort studies were included, for a total of 499,854 patients. The analysis from adjusted estimates of the primary outcome showed substantial heterogeneity (I 2 = 89%, very low certainty evidence) and was narratively summarised. Female sex was associated with reduced odds of AED pad application compared with males (OR 0.79; 95% CI 0.66-0.94; P = 0.008; I 2 = 45%; moderate certainty evidence).

Conclusions

The evidence regarding the association between bystander CPR initiation and patient's sex is characterised by substantial heterogeneity. Female sex appears to be associated with a lower probability of AED pad application compared with males.

Cardiac Arrest in Outpatient Hemodialysis Units: A National Cross-Sectional Survey of Dialysis Technicians

RATIONALE & OBJECTIVE

Cardiac arrest is the leading cause of death for hemodialysis patients and often occurs within outpatient dialysis units. Approximately one-fifth of dialysis unit resuscitations are not initiated until emergency medical service personnel arrive. Little is known about the training and preparedness of dialysis patient care technicians (PCTs) to provide cardiopulmonary resuscitation (CPR).

STUDY DESIGN

Cross-sectional national survey.

SETTING & PARTICIPANTS

Survey of National Association of Nephrology Technicians/Technologists members.

ANALYTICAL APPROACH

Descriptive statistics were performed for all survey variables. A Likert scale (5 point) was used for self-efficacy questions about the critical steps of basic life support (BLS), and subgroups were compared using χ2 test. The top 3 challenges for performing high-quality CPR were ranked by the participants.

RESULTS

The survey participants were 100 dialysis PCTs representing 31 US states, with 97% reporting BLS training within the last 2 years. Eighty percent had witnessed a dialysis clinic cardiac arrest. The participants had high levels of confidence for performing each step of BLS (65% ± 7% selecting 5/5 on the Likert scale), but only 33% reported the same confidence level in their dialysis team's ability to resuscitate a patient. Dialysis PCTs with more work experience and in larger units reported significantly higher team confidence. For positioning, 51% indicated that optimal CPR should be performed directly in the dialysis chair, and 47% indicated that moving the patient from the chair to the floor was necessary. Participants cited delays in recognizing cardiac arrest and fear of harming the patient as the most significant barriers to performing CPR in dialysis clinics.

LIMITATIONS

Small sample size and sampling bias may limit generalizability.

CONCLUSIONS

Although the participants reported having up-to-date training and high confidence in their BLS skills, their confidence in team resuscitation was comparably low, and there was no consensus on positioning for CPR. Quality improvement efforts should focus on team training and the unique barriers to CPR presented by the dialysis clinic setting.

PLAIN-LANGUAGE SUMMARY

Despite the need for a rapid response to cardiac arrest, cardiopulmonary resuscitation (CPR) is not always initiated by staff in the dialysis unit before the arrival of emergency medical services. Little is known about the barriers that dialysis patient care technicians (PCTs) face in performing CPR in outpatient dialysis units. We surveyed dialysis PCTs on their experience with CPR training and performance. We found that dialysis PCTs were up to date on training and were individually confident in their CPR skills but were less confident in their teams' abilities to perform effective CPR. There was a lack of agreement on how to position patients for CPR. Future efforts should focus on improving team training and addressing the unique challenges of treating cardiac arrests that occur in the dialysis clinic.

Cardiac arrest: Pre-hospital strategies to facilitate successful resuscitation and improve recovery rates

The estimated annual incidence of out-of-hospital cardiac arrest (OHCA) is approximately 120 cases per 100000 inhabitants in western countries. Although the rates of bystander cardiopulmonary resuscitation (CPR) and use of automated external defibrillator are increasing, the likelihood of survival to hospital discharge is no more than 8%. To date, various devices and methods have been utilized in the initial CPR approach targeting to improve survival and neurological outcomes in OHCA patients. The aim of this review is to discuss strategies that facilitate resuscitation, increase the chance to achieve return to spontaneous circulation and improve survival to hospital discharge and neurological outcomes in the pre-hospital setting.

Assessing Attitudes and Perceptions of High-Risk, Low-Resource Communities Towards Cardiopulmonary Resuscitation and Public-Access Defibrillation

Background: Layperson cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use are vital for improving survival rates after out-of-hospital cardiac arrest (OHCA), yet their application varies by community demographics. We evaluated the concerns and factors influencing willingness to perform CPR and use AEDs among laypersons in high-risk, low-resource communities. Methods: From April 2022 to March 2024, laypersons in Northern Manhattan's Community District 12 completed surveys assessing their attitudes toward CPR and AED use before attending Hands-Only CPR training. Fisher's Exact Test assessed differences in concerns and willingness to perform CPR and AED use across racial-ethnic groups and compared low-resource communities with high-resource groups consisting of non-clinical staff across eight ambulatory sites. Results: Among 669 participants from low-resource communities, 64% identified as Hispanic, 58% were under 40 years of age, and 67% were female. Significant knowledge gaps were identified: 62% had never learned CPR, and 77% were unfamiliar with AEDs. Top concerns about giving CPR included fear of incorrect performance (67%), causing harm (56%), and legal repercussions (53%). Willingness to perform CPR was most influenced by familiarity with the victim. The primary barrier to AED use was a lack of operational knowledge (66%). Non-Hispanic Black participants expressed significantly greater concerns than their Non-Hispanic White counterparts. Participants in high-resource settings (n = 309) showed higher training rates, albeit with similar apprehensions about CPR and AED use. Conclusions: Concerns regarding CPR and AED use stem from a lack of confidence and training, particularly predominant in certain racial-ethnic groups. Targeted, culturally sensitive community interventions could potentially address these barriers, enhance preparedness, and improve OHCA survival rates.

Teaching high quality paediatric basic life support to laypeople: The development and evaluation of a virtual simulation game

Background

Self-directed training has been recognized as a reasonable alternative to traditional instructor-led formats to teach laypeople Basic Life Support (BLS). Virtual tools can facilitate high-quality self-directed resuscitation education; however, their role in teaching paediatric BLS remains unclear due to limited empiric evaluation and suboptimal design of existing tools.

Aim

We describe the development and evaluation of a virtual simulation game (VSG) designed to teach high-quality paediatric BLS using a self-directed, online format with integrated deliberate practice and feedback.

Methods

We conducted a pilot prospective single-arm cohort study examining the VSG's impact on laypeople's paediatric BLS self-efficacy, attitudes, and knowledge as well as learner reactions. Data was collected using online surveys immediately after VSG completion and was analysed using descriptive statistics.

Results

Fifty-five participants (median age 32 years, 76% female, 11% active certification in paediatric BLS) evaluated the VSG. Participants reported high self-efficacy, willingness to perform paediatric BLS, and high perceived knowledge after VSG completion. Fifty (91%) achieved a passing score (≥13/15) on the paediatric BLS knowledge assessment. Learner reactions were favourable with 98% of participants agreeing that VSG educational content was clear and helpful. Mean System Usability Scale score was 81.1 (standard deviation 12.6) with a Net Promoter Score of 32 indicating high levels of usability and likelihood to recommend to others.

Conclusions

The VSG was well-received by laypeople with positive effects observed on paediatric BLS self-efficacy, attitudes, and knowledge. Future studies should examine the impact of VSGs on skill performance through standalone or blended learning approaches.

Drones delivering automated external defibrillators for out-of-hospital cardiac arrest: A scoping review

Out-of-hospital cardiac arrest (OHCA) remains a critical health concern, where prompt access to automated external defibrillators (AEDs) significantly improves survival. This scoping review broadly investigates the feasibility and impact of dronedelivered AEDs for OHCA response.

METHODS

PubMed, Cochrane, and Web of Science were searched from inception to August 6, 2024, with eligibility broadly including empirical data. The charting process involved iterative data extraction for thematic analysis.

RESULTS

We identified 306 titles and, after duplicate removal, title/abstract screening, and full text review, included 39 studies. These were divided into three categories: 1) Real-world observational studies (n = 3), 2) Test flights/simulation studies and qualitative analyses (n = 15), and 3) Computer/prediction models (n = 21). Real-world studies demonstrated the feasibility of drone AED delivery, with a time advantage of 01:52 - 03:14 min over ambulances observed in 64-67 % of cases. Test flight/simulation and qualitative studies consistently reported feasibility and positive bystander experiences. Computer/prediction models exhibited considerable heterogeneity, yet all indicated significant time savings for AED delivery compared to traditional EMS methods. Moreover, seven studies estimated improved survival rates, with five assessing cost-effectiveness and favouring drone systems. Regional factors such as EMS response times, volunteer responder programmes, terrain, weather, and budget constraints influenced the system's effectiveness.

CONCLUSION

Across all categories, studies confirmed the feasibility of drone-delivered AED systems, with significant potential for reducing time to AED arrival compared to EMS arrival. Prediction models suggested enhanced survival alongside costeffectiveness. Further research, including more extensive real-world studies and regulatory advancements, is imperative to integrate drones effectively into OHCA response systems.

Evaluating video-supported layperson CPR compared to a standard training course: A randomized controlled trial

Background

While just-in-time (JIT) training is associated with time and cost savings, limited evidence directly compares layperson CPR performance using JIT videos to in-person CPR courses. We measured layperson CPR performance using a JIT video compared to an in-person course or no training.

Methods

Adult employees at a professional sports stadium were randomized to perform CPR in a simulated scenario a) after completing an AHA HeartSaver® course, b) using a JIT training video, or c) neither (control). CPR performance was assessed by trained evaluators and QCPR-enabled simulators. The primary outcome was the performance of pre-defined critical actions. Participants were blinded to study objectives and trained evaluators used standardized checklists.

Results

Of 230 eligible subjects, 221 were included in analysis, without significant differences in group characteristics. Correct CPR performance was low, though significantly higher in the AHA group (AHA: 40%, 95%CI 28-51; JIT: 15%, 95%CI 8-26; control 10%, 95%CI 4-19). Compression fraction was significantly greater in the AHA group (90%, IQR 69-98) compared to JIT (61%, IQR 29-89) or control (65%, IQR 33-93). An AED was requested more frequently in the AHA group (47%) than in the JIT (15%) or control (10%) groups.

Conclusions

While overall performance of correct CPR skills was best following a traditional CPR course, laypersons using real-time video training performed as well as those taking an AHA HeartSaver® course on several key measures including time to chest compressions and compression rate.Trial Registration.NCT05983640.

Ethical issues in termination of resuscitation decision-making: an interview study with paramedics and relatives of out-of-hospital cardiac arrest non-survivors

BACKGROUND

In out-of-hospital cardiac arrest (OHCA), decisions to terminate resuscitation or transport the patient to hospital are ethically fraught. However, little is known about paramedics' ethical concerns in these decision-making processes.

OBJECTIVE

To develop an understanding of how paramedics experience ethical concerns in OHCA decision-making processes, and how this relates to the ethical concerns of patients' relatives.

DESIGN

A qualitative study using semi-structured interviews with paramedics and relatives of OHCA non-survivors.

SETTING

Two ambulance trusts in England.

PARTICIPANTS

Thirty-one paramedics, identified as decision-makers in adult OHCA events in which cardiopulmonary resuscitation (CPR) had been initiated, were interviewed. Fourteen interviews with relatives of OHCA non-survivors were also conducted.

ANALYSIS

The interviews were analysed thematically, using a coding framework and following an empirical ethics approach.

RESULTS

Four themes were developed: preventing harm to patients, best interests, caring for the patient's family and moral distress. Paramedics conceptualised preventing harm both as saving lives and as preventing an undignified death or a life with severe brain damage. Paramedics' and relatives' views of best interests were influenced by values such as patient dignity and assumptions about age and quality of life. Paramedics expressed a duty of care towards the patient's family. Relatives conveyed the importance of clear communication and acts of care performed by the ambulance crew, underscoring the ethical commitment that paramedics had towards patients' families. Paramedics described decision-making processes that relied on clinical guidelines, rather than personal values and beliefs; this sometimes led to moral distress.

CONCLUSION

Non-protocolised ethical considerations are important in paramedic decision-making about terminating CPR in OHCA events. While paramedics use established guidelines and processes to reach decisions that prevent patient harm, they experience moral distress when personal convictions clash with guidelines. Training around ethical reasoning and decision making may help paramedics reduce their moral distress and provide consistent and transparent decisions for patients and their families.

Give Your Toys a Broader Story: Simulation for Advocacy, Community Education, and Empowerment

As we better understand how to deliver the most effective medical simulation, the applications and indications are growing. One way to extend the impact of these tools and methods is for community education and empowerment. Developing mobile simulation units with the intent to reach health care and community settings is a way to add value to a costly but worthy endeavor. Here we focus on developing bundles of medical simulation for pediatric populations and their families, including curricular objectives, considerations for psychological safety, and operations. [Pediatr Ann. 2024;53(11):e420-e424.].

Bystanders' willingness to assist using automated external defibrillators during cardiac arrest

The "bystander effect," in which the presence of others inhibits rescue actions, has not been specifically examined in the context of cardiac arrest; understanding this effect in relation to rescue with automated external defibrillators (AEDs) is important. This study aims to identify the presence of others as a factor inhibiting rescue actions using an AED, from a social psychology perspective. We collected data through a web-based questionnaire involving registered residents in all 47 prefectures of Japan. The participants were presented with hypothetical scenarios of witnessing cardiac arrest events at train stations, under sparse or crowded conditions, and with or without the presence of competent parties (e.g., station staff or security guards). Their willingness to intervene was assessed across three levels of rescue behavior: (1) running and calling for help, (2) retrieving an AED, and (3) using an AED. This study found evidence of the bystander effect, indicating that the presence of competent others reduced behavioral interventions by bystanders during out-of-hospital cardiac arrest (OHCA) events. Moreover, the perceived presence of competent parties at the scene of a cardiac arrest reduced bystanders' willingness to initiate rescue under certain circumstances. While many bystanders were willing to initiate rescue efforts in response to calls for help, they resisted rescues involving an AED. This study observes that a bystander effect occurs among bystanders witnessing OHCA, explores the inhibiting effects of identifying competent parties on the initiation of rescue efforts, and suggests that there are significant invisible barriers to using AEDs in rescuing patients with OHCA.

Training experience is an important factor affecting willingness for bystander CPR and awareness of AED: a survey of residents from a province in Central China in 2023

Background

Bystander cardiopulmonary resuscitation (CPR) and the use of automated external defibrillators (AEDs) may improve survival in patients with out-of-hospital cardiac arrest (OHCA). The purpose of this study was to investigate the effect of CPR training experience and sociodemographic characteristics on bystander CPR willingness and AED awareness.

Methods

In this study, a questionnaire survey was conducted among 3,569 residents in central China. Descriptive statistics, multiple linear regression and multivariate logistic regression modeling were used to investigate the effect of training experience and sociodemographic characteristics on knowledge of cardiac arrest first aid, awareness of AEDs, and willingness for bystander CPR.

Results

Of the 3,569 participants, nearly 52% were female, 69.6% were < 23 years old, 23.5% had CPR training and 22.1% had witnessed OHCA. Characteristics of increasing bystander CPR willingness included CPR training experience, male, witnessed OHCA but not acting, knowing whether family members have cardiac disease, older age (>40 years) and lower level of education. Farmers were the subgroup with the least awareness of AED and knowledge of first aid.

Conclusion

In China, CPR training experience was an important factor in improving bystanders' CPR willingness, AED awareness and knowledge of cardiac arrest first aid. Additionally, having witnessed OHCA also had a positive effect on bystander CPR willingness.

Cardiac Arrest and Cardiopulmonary Resuscitation Outcome Reports: 2024 Update of the Utstein Out-of-Hospital Cardiac Arrest Registry Template

The Utstein Out-of-Hospital Cardiac Arrest Resuscitation Registry Template, introduced in 1991 and updated in 2004 and 2015, standardizes data collection to enable research, evaluation, and comparisons of systems of care. The impetus for the current update stemmed from significant advances in the field and insights from registry development and regional comparisons. This 2024 update involved representatives of the International Liaison Committee on Resuscitation and used a modified Delphi process. Every 2015 Utstein data element was reviewed for relevance, priority (core or supplemental), and improvement. New variables were proposed and refined. All changes were voted on for inclusion. The 2015 domains-system, dispatch, patient, process, and outcomes-were retained. Further clarity is provided for the definitions of out-of-hospital cardiac arrest attended resuscitation and attempted resuscitation. Changes reflect advancements in dispatch, early response systems, and resuscitation care, as well as the importance of prehospital outcomes. Time intervals such as emergency medical service response time now emphasize precise reporting of the times used. New flowcharts aid the reporting of system effectiveness for patients with an attempted resuscitation and system efficacy for the Utstein comparator group. Recognizing the varying capacities of emergency systems globally, the writing group provided a minimal dataset for settings with developing emergency medical systems. Supplementary variables are considered useful for research purposes. These revisions aim to elevate data collection and reporting transparency by registries and researchers and to advance international comparisons and collaborations. The overarching objective remains the improvement of outcomes for patients with out-of-hospital cardiac arrest.

Extracorporeal Cardiopulmonary Resuscitation: Life-saving or Resource Wasting?

The morbidity and mortality for patients having a cardiac arrest is substantial. Even if optimally performed, conventional cardiopulmonary resuscitation is an inadequate substitute for native cardiac output and results in a 'low-flow' perfusion state. Venoarterial extracorporeal membrane oxygenation during cardiac arrest, also known as extracorporeal cardiopulmonary resuscitation (eCPR), has been proposed as an alternative to restore systemic perfusion. However, conflicting results regarding its efficacy compared to routine advanced cardiac life support have left its role in clinical practice uncertain. In this article, the merits and limitations of the existing data for eCPR are reviewed in a 'point- counterpoint' style debate, followed by potential considerations for future trials.

Cardiac arrest and cardiopulmonary resuscitation outcome reports: 2024 update of the Utstein Out-of-Hospital Cardiac Arrest Registry template

The Utstein Out-of-Hospital Cardiac Arrest Resuscitation Registry Template, introduced in 1991 and updated in 2004 and 2015, standardizes data collection to enable research, evaluation, and comparisons of systems of care. The impetus for the current update stemmed from significant advances in the field and insights from registry development and regional comparisons. This 2024 update involved representatives of the International Liaison Committee on Resuscitation and used a modified Delphi process. Every 2015 Utstein data element was reviewed for relevance, priority (core or supplemental), and improvement. New variables were proposed and refined. All changes were voted on for inclusion. The 2015 domains-system, dispatch, patient, process, and outcomes-were retained. Further clarity is provided for the definitions of out-of-hospital cardiac arrest attended resuscitation and attempted resuscitation. Changes reflect advancements in dispatch, early response systems, and resuscitation care, as well as the importance of prehospital outcomes. Time intervals such as emergency medical service response time now emphasize precise reporting of the times used. New flowcharts aid the reporting of system effectiveness for patients with an attempted resuscitation and system efficacy for the Utstein comparator group. Recognizing the varying capacities of emergency systems globally, the writing group provided a minimal dataset for settings with developing emergency medical systems. Supplementary variables are considered useful for research purposes. These revisions aim to elevate data collection and reporting transparency by registries and researchers and to advance international comparisons and collaborations. The overarching objective remains the improvement of outcomes for patients with out-of-hospital cardiac arrest.

Incidence and Survival of Out-of-Hospital Cardiac Arrest in Public Housing Areas in 3 European Capitals

BACKGROUND

Strategies to reach out-of-hospital cardiac arrests (called cardiac arrest) in residential areas and reduce disparities in care and outcomes are warranted. This study investigated incidences of cardiac arrests in public housing areas.

METHODS

This register-based cohort study included cardiac arrest patients from Amsterdam (the Netherlands) from 2016 to 2021, Copenhagen (Denmark) from 2016 to 2021, and Vienna (Austria) from 2018 to 2021. Using Poisson regression adjusted for spatial correlation and city, we compared cardiac arrest incidence rates (number per square kilometer per year and number per 100 000 inhabitants per year) in public housing and other residential areas and examined the proportion of cardiac arrests within public housing and adjacent areas (100-m radius).

RESULTS

Overall, 9152 patients were included of which 3038 (33.2%) cardiac arrests occurred in public housing areas and 2685 (29.3%) in adjacent areas. In Amsterdam, 635/1801 (35.3%) cardiac arrests occurred in public housing areas; in Copenhagen, 1036/3077 (33.7%); and in Vienna, 1367/4274 (32.0%). Public housing areas covered 42.4 (12.6%) of 336.7 km2 and 1 024 470 (24.6%) of 4 164 700 inhabitants. Across the capitals, we observed a lower probability of 30-day survival in public housing versus other residential areas (244/2803 [8.7%] versus 783/5532 [14.2%]). The incidence rates and rate ratio of cardiac arrest in public housing versus other residential areas were incidence rate, 16.5 versus 4.1 n/km2 per year; rate ratio, 3.46 (95% CI, 3.31-3.62) and incidence rate, 56.1 versus 36.8 n/100 000 inhabitants per year; rate ratio, 1.48 (95% CI, 1.42-1.55). The incidence rates and rate ratios in public housing versus other residential areas were consistent across the 3 capitals.

CONCLUSIONS

Across 3 European capitals, one-third of cardiac arrests occurred in public housing areas, with an additional third in adjacent areas. Public housing areas exhibited consistently higher cardiac arrest incidences per square kilometer and 100 000 inhabitants and lower survival than other residential areas. Public housing areas could be a key target to improve cardiac arrest survival in countries with a public housing sector.

A novel approach to community CPR and AED outreach focused on underserved learner communities

Creating a sustainable community cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) program that reaches underserved communities poses a challenge for the emergency medical services (EMS) community. Attendance, funding, and resources have all been linked to struggles surrounding community CPR/AED programs. Through our experience in conducting CPR/AED trainings in underserved regions of eastern North Carolina, we propose a method of effectively utilizing existing organizations and institutions of learning to expand and maintain a sustainable community CPR/AED program. Furthermore, we demonstrate 10 cornerstones in developing relationships within the community to increase attendance and participation in diverse communities.

Evaluation of the willingness to perform cardiopulmonary resuscitation (CPR) with automated external defibrillator (AED) among Hong Kong Chinese using the theory of planned behaviour framework: an online cross-sectional survey

Introduction

Bystander cardiopulmonary resuscitation (CPR) and defibrillation by an automated external defibrillator (AED) in out-of-hospital cardiac arrest (OHCA) events were low in Hong Kong (HK). This study evaluated the willingness and associated factors of performing CPR with AED in HK using the theory of planned behaviour (TPB).

Methods

A total of 1449 responses from HK Chinese aged 15-64 years were collected in a cross-sectional online survey using convenience sampling on social media including Facebook, Instagram and WhatsApp. Three TPB determinants, namely attitude, subjective norm and perceived behavioural control; and perceived barriers were asked using 5-point Likert scales. Associations between each predictor and willingness to perform CPR with AED were evaluated using univariate ordinal regressions. Predictive models were constructed using hierarchical multiple ordinal regressions (MOR) to explore associated predictors and the adjusted OR (ORadj).

Results

There were 44.8% and 47.8% of respondents who were willing to perform CPR and use AED, respectively. Young adults aged 18-25 years demonstrated the lowest willingness to perform CPR (ORadj=0.63, 95% CI 0.42 to 0.94, p=0.023). Knowledge level was not associated with either CPR or AED willingness, thus was eliminated in backward selection in the MOR. Attitude, subjective norm and perceived behavioural control were all positively associated with both willingness (all ORadj>1.5, p<0.001), while perceived barriers were associated with CPR willingness only (ORadj=0.77, 95% CI 0.66 to 0.91, p=0.002).

Conclusions

Utilisation of the TPB framework in CPR and AED community education would fill the 'know-do' gap and enhance the community's willingness to perform CPR and use an AED.

Intentional interruptions during compression only CPR: A scoping review

Introduction

Out of hospital cardiac arrest (OHCA) remains one of the main causes of death among industrialized countries. The initiation of cardiopulmonary resuscitation (CPR) by laypeople before the arrival of emergency medical services improves survival. Mouth-to-mouth ventilation may constitute a hindering factor to start bystander CPR, while during continuous chest compressions (CCC) CPR quality decreases rapidly. The aim of this scoping review is to examine the existing literature on strategies that investigate the inclusion of intentional pauses during compression-only resuscitation (CO-CPR) to improve the performance in the context of single lay rescuer OHCA.

Methods

The protocol of this Scoping review was prospectively registered in Open Science Framework (https://osf.io/rvn8j). A systematic search of PubMed, Scopus, EMBASE, CINAHL was performed.

Results

Six articles were included. All studies were carried out on simulation manikins and involved a total of 1214 subjects. One study had a multicenter design. Three studies were randomized controlled simulation trials, the rest were prospective randomized crossover studies. The tested protocols were heterogeneous and compared CCC to CO-CPR with intentional interruptions of various length. The most common primary outcome was compressions depth. Compression rate, rescuers' perceived exertion and composite outcomes were also evaluated. Compressions depth and perceived exertion improved in most study groups while compression rate and chest compression fraction remained within guidelines indications.

Conclusions

In simulation studies, the inclusion of intentional interruptions during CO-CPR within the specific scenario of single rescuer bystander CPR during OHCA may improve the rate of compressions with correct depth and lower rate of perceived exertion. Further high-quality research and feasibility and safety of protocols incorporating intentional interruptions during CO-CPR may be justified.

Factors influencing civil servants' willingness to implement cardiopulmonary resuscitation in Chongqing, China: Based on the theory of planned behavior

Background

Timely bystander cardiopulmonary resuscitation is the key to improving the survival rate of out-of-hospital cardiac arrest. Civil servants are potential bystander CPR providers. This study aimed to explore civil servants' willingness to implement CPR in Chongqing, identify the influencing factors and mechanisms affecting civil servants' willingness to perform CPR, and then seek countermeasures to improve civil servants' willingness to implement CPR.

Methods

We introduced the theory of perceived risk into the theory of planned behavior, developed a 7-point Likert scale based on the extended theory of planned behavior, and conducted a questionnaire survey on civil servants in Chongqing, China. Descriptive statistical analysis and one-way ANOVA were employed to explore respondents' willingness and differences. Structural equation modeling was used to analyze the relationship between attitude, subjective norm, perceived behavioral control and perceived risk and respondents' willingness to implement CPR.

Results

A total of 1235 valid questionnaires were included for analysis. 50.1 % of respondents were willing to implement CPR. Male, over 40 years old, living with the elderly, having previous experience performing CPR on another person, and having higher CPR knowledge scores were associated with a more positive willingness to perform CPR. Attitude, subjective norm and perceived behavioral control had significant positive effects on willingness, and the standardized regression coefficients were 0.164, 0.326 and 0.313, respectively. The perceived risk has a significant negative effect on willingness, and the standardized regression coefficient was -0.109. The four latent variables accounted for 44.2 % of the variance in the willingness of civil servants to implement CPR.

Conclusions

The willingness of civil servants in Chongqing to implement CPR needs to be improved, and the countermeasures to enhance the subjective norm and perceived behavioral control of civil servants should be emphasized, such as developing a social support network for rescuing conduct, establishing regular training mechanisms and improving the practical applicability and popularization of the Chinese-style "Good Samaritan Law" etc., to improve the willingness of civil servants in Chongqing to implement CPR.

Qualitative research in cardiac arrest research: A narrative review

Qualitative research is defined as "the study of the nature of phenomena", including "their quality, different manifestations, the context in which they appear or the perspectives from which they can be perceived". It is a methodology which is becoming extremely valuable in resuscitation science, especially in terms of improving our understanding of the true impact of sudden cardiac arrest on survivors, family members, lay responders and health care providers. This narrative review provides a high-level overview of qualitative methods as well as the current state of the qualitative evidence and key knowledge gaps in resuscitation science. It finishes with discussion of the bright future of qualitative research in our field.

Compression-Only or Standard Cardiopulmonary Resuscitation for Trained Laypersons in Out-of-Hospital Cardiac Arrest: A Nationwide Randomized Trial in Sweden

BACKGROUND

The ongoing TANGO2 (Telephone Assisted CPR. AN evaluation of efficacy amonGst cOmpression only and standard CPR) trial is designed to evaluate whether compression-only cardiopulmonary resuscitation (CPR) by trained laypersons is noninferior to standard CPR in adult out-of-hospital cardiac arrest. This pilot study assesses feasibility, safety, and intermediate clinical outcomes as part of the larger TANGO2 survival trial.

METHODS

Emergency medical dispatch calls of suspected out-of-hospital cardiac arrest were screened for inclusion at 18 dispatch centers in Sweden between January 1, 2017, and March 12, 2020. Inclusion criteria were witnessed event, bystander on the scene with previous CPR training, age above 18 years of age, and no signs of trauma, pregnancy, or intoxication. Cases were randomized 1:1 at the dispatch center to either instructions to perform compression-only CPR (intervention) or instructions to perform standard CPR (control). Feasibility included evaluation of inclusion, randomization, and adherence to protocol. Safety measures were time to emergency medical service dispatch CPR instructions, and to start of CPR, intermediate clinical outcome was defined as 1-day survival.

RESULTS

Of 11 838 calls of suspected out-of-hospital cardiac arrest screened for inclusion, 2168 were randomized and 1250 (57.7%) were out-of-hospital cardiac arrests treated by the emergency medical service. Of these, 640 were assigned to intervention and 610 to control. Crossover from intervention to control occurred in 16.3% and from control to intervention in 18.5%. The median time from emergency call to ambulance dispatch was 1 minute and 36 s (interquartile range, 1.1-2.2) in the intervention group and 1 minute and 30 s (interquartile range, 1.1-2.2) in the control group. Survival to 1 day was 28.6% versus 28.4% (P=0.984) for intervention and control, respectively.

CONCLUSIONS

In this national randomized pilot trial, compression-only CPR versus standard CPR by trained laypersons was feasible. No differences in safety measures or short-term survival were found between the 2 strategies. Efforts to reduce crossover are important and may strengthen the ongoing main trial that will assess differences in long-term survival.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02401633.

Factors influencing support for the implementation of community-based out-of-hospital cardiac arrest interventions in high- and low-performing counties

Aim of the study

Survival to hospital discharge from out-of-hospital cardiac arrest (OHCA) after receiving treatment from emergency medical services (EMS) is less than 10% in the United States. Community-focused interventions improve survival rates, but there is limited information on how to gain support for new interventions or program activities within these populations. Using data from the RAndomized Cluster Evaluation of Cardiac ARrest Systems (RACE-CARS) trial, we aimed to identify the factors influencing emergency response agencies' support in implementing an OHCA intervention.

Methods

North Carolina counties were stratified into high-performing or low-performing counties based on the county's cardiac arrest volume, percent of bystander-cardiopulmonary resuscitation (CPR) performed, patient survival to hospital discharge, cerebral performance in patients after cardiac arrest, and perceived engagement in the RACE-CARS project. We randomly selected 4 high-performing and 3 low-performing counties and conducted semi-structured qualitative interviews with emergency response stakeholders in each county.

Results

From 10/2021 to 02/2022, we completed 29 interviews across the 7 counties (EMS (n = 9), telecommunications (n = 7), fire/first responders (n = 7), and hospital representatives (n = 6)). We identified three themes salient to community support for OHCA intervention: (1) initiating support at emergency response agencies; (2) obtaining support from emergency response agency staff (senior leadership and emergency response teams); and (3) and maintaining support. For each theme, we described similarities and differences by high- and low-performing county.

Conclusions

We identified techniques for supporting effective engagement of emergency response agencies in community-based interventions for OHCA improving survival rates. This work may inform future programs and initiatives around implementation of community-based interventions for OHCA.

Willingness and Barriers to Undertaking Cardiopulmonary Resuscitation Reported by Medical Students after the SARS-CoV-2 Pandemic-Single-Center Study

Most of the studies in the field of willingness and barriers to resuscitation (CPR) were conducted before the SARS-CoV-2 pandemic. The aim of the study was to assess the number and types of barriers to CPR among medical students after the pandemic ended. This study was based on a survey. The data was collected from 12 April 2022 to 25 May 2022. A total of 509 complete questionnaires were obtained. The number of barriers depending on the time elapsed from the last CPR course did not differ significantly (Me = 4 [IQR 2-6] vs. Me = 5 [IQR 3-7]; p = 0.054, respectively). The number of all barriers reported by respondents differed significantly and was higher in those reporting fear of coronavirus (Me = 4 [IQR 2-6] vs. Me = 7 [IQR 4-9]; p < 0.001, respectively). A total of 12 out of all 23 barriers were significantly more frequent in this group of respondents. Barriers to CPR are still common among medical students, even despite a high rate of CPR training. The pandemic significantly affected both the number and frequency of barriers. The group of strangers and children, as potential cardiac arrest victims, deserve special attention. Efforts should be made to minimize the potentially modifiable barriers.

Wolf Creek XVII Part 5: Mobile AEDs

Introduction

Millions of out-of-hospital cardiac arrests (OHCA) occur globally each year. Survival after OHCA can be improved with the use of automated external defibrillators (AED). The main strategy for facilitating bystander defibrillation has been fixed-location public access defibrillators (PADs). New strategies of mobile AEDs depart from the model of static PADs and have the potential to address known barriers to early defibrillation and improve outcomes.

Methods

Mobile AEDs was one of six focus topics for the Wolf Creek XVII Conference held on June 14-17, 2023, in Ann Arbor, Michigan, USA. Conference invitees included international thought leaders and scientists in the field of cardiac arrest resuscitation from academia and industry. Participants submitted via online survey knowledge gaps, barriers to translation and research priorities for each focus topic. Expert panels used the survey results and their own perspectives and insights to create and present a preliminary unranked list for each category that was debated, revised, and ranked by all attendees to identify the top 5 for each category.

Results

Top knowledge gaps center around understanding the impact of mobile AEDs on OHCA outcomes in various settings and the impact of novel AED technologies. Top barriers to translation include questionable public comfort/acceptance, financial/regulatory constraints, and a lack of centralized accountability. Top research priorities focus on understanding the impact of the mobile AED strategies and technologies on time to defibrillation and OHCA outcomes.

Conclusion

This work informs research agendas, funding priorities and policy decisions around using mobile AEDs to optimize prehospital response to OHCA.

Public Out-of-Hospital Cardiac Arrest in Residential Neighborhoods

BACKGROUND

Although one-half of all public out-of-hospital cardiac arrests (OHCAs) occur outside private homes in residential neighborhoods, their characteristics and outcomes remain unexplored.

OBJECTIVES

The authors assessed interventions before ambulance arrival and survival for public OHCA patients in residential neighborhoods.

METHODS

Public OHCAs from Vienna (2018-2021) and Copenhagen (2016-2020) were designated residential neighborhoods or nonresidential areas. Interventions (cardiopulmonary resuscitation [CPR], automated external defibrillator [AED] attached, and defibrillation) and 30-day survival were compared using a generalized estimation equation model adjusted for age and time of day and presented as ORs.

RESULTS

We included 1,052 and 654 public OHCAs from Vienna and Copenhagen, respectively, and 68% and 55% occurred in residential neighborhoods, respectively. The likelihood of CPR, defibrillation, and survival in residential neighborhoods vs nonresidential areas (reference) were as follows: CPR Vienna, 73% vs 78%, OR: 0.78 (95% CI: 0.57-1.06), CPR Copenhagen, 83% vs 90%, OR: 0.54 (95% CI: 0.34-0.88), and CPR combined, 76% vs 84%, OR: 0.70 (95% CI: 0.53-0.90); AED attached Vienna, 36% vs 44%, OR: 0.69 (95% CI: 0.53-0.90), AED attached Copenhagen, 21% vs 43%, OR: 0.33 (95% CI: 0.24-0.48), and AED attached combined, 31% vs 44%, OR: 0.53 (95% CI: 0.42-0.65); defibrillation Vienna, 14% vs 20%, OR: 0.61 (95% CI: 0.43-0.87), defibrillation Copenhagen, 16% vs 36%, OR: 0.35 (95% CI: 0.24-0.51), and defibrillation combined, 15% vs 27%, OR: 0.46 (95% CI: 0.36-0.61); and 30-day survival rate Vienna, 21% vs 26%, OR: 0.84 (95% CI: 0.58-1.20), 30-day survival rate Copenhagen, 33% vs 44%, OR: 0.65 (95% CI: 0.47-0.90), and 30-day survival rate combined, 25% vs 36%, OR: 0.73 (95% CI: 0.58-0.93).

CONCLUSIONS

Two-thirds of public OHCAs occurred in residential neighborhoods with fewer resuscitative efforts before ambulance arrival and lower survival than in nonresidential areas. Targeted efforts to improve early CPR and defibrillation for public OHCA patients in residential neighborhoods are needed.

Emergency Medicine Perspectives: The Importance of Bystanders and Their Impact on On-Site Resuscitation Measures and Immediate Outcomes of Out-of-Hospital Cardiac Arrest

INTRODUCTION

Out-of-hospital cardiac arrests (OHCAs) represent critical medical emergencies in which timely interventions can make a significant difference in patient outcomes. Despite their importance, the role of on-scene witnesses during such events remains relatively unexplored.

AIM OF THE STUDY

This research seeks to shed light on the influence of witnesses, especially family members, during OHCAs and the effect of their interventions, or the absence thereof, on outcomes. Drawing from existing literature, our working hypothesis suggests that the presence of a witness, particularly one who is knowledgeable about CPR, can increase the likelihood of obtaining the return of spontaneous circulation (ROSC), potentially enhancing overall survival rates.

METHODS

Using a retrospective analytical method, we thoroughly reviewed medical records from the Lublin Voivodeship between 2014-2017. Out of 5111 events identified using ICD-10 diagnosis codes and ICD-9 medical procedure codes, 4361 cases specifically related to sudden cardiac arrest were chosen. Concurrently, 750 events were excluded based on predefined criteria.

RESULTS

Both basic and advanced EMS teams showed higher rates of CPR initiation and an increased likelihood of obtaining ROSC. Notably, the presence of a trained EMS professional as a witness significantly increased the chances of CPR initiation. The presenting rhythms most often detected were ventricular tachycardia (VT) and ventricular fibrillation (VF). Different urgency codes were directly linked to varying ROSC outcomes. When witnesses, especially family members, began chest compressions, the use of amiodarone was notably higher. A significant finding was that 46.85% of OHCA patients died without witnesses, while family members were present in 23.87% of cases. Actions taken by witnesses, especially chest compressions, generally extended the overall duration of patient care.

CONCLUSION

The crucial influence of witnesses, particularly family members, on OHCA outcomes is evident. Therefore, it is essential to increase public awareness of CPR techniques and rapid intervention strategies to improve outcomes in emergency situations.

Community intervention to improve defibrillation before ambulance arrival in residential neighbourhoods with a high risk of out-of-hospital cardiac arrest: study protocol of a cluster-randomised trial (the CARAMBA trial)

INTRODUCTION

In Denmark, multiple national initiatives have been associated with improved bystander defibrillation and survival following out-of-hospital cardiac arrest (OHCA) in public places. However, OHCAs in residential neighbourhoods continue to have poor outcomes. The Cardiac Arrest in Residential Areas with MoBile volunteer responder Activation trial aims to improve bystander defibrillation and survival following OHCA in residential neighbourhoods with a high risk of OHCA. The intervention consists of: (1) strategically deployed automated external defibrillators accessible at all hours, (2) cardiopulmonary resuscitation (CPR) training of residents and (3) recruitment of residents for a volunteer responder programme.

METHODS AND ANALYSIS

This is a prospective, pair-matched, cluster-randomised, superiority trial with clusters of 26 residential neighbourhoods, testing the effectiveness of the intervention in a real-world setting. The areas are randomised for intervention or control. Intervention and control areas will receive the standard OHCA emergency response, including volunteer responder activation. However, targeted automated external defibrillator deployment, CPR training and volunteer responder recruitment will only be provided in the intervention areas. The primary outcome is bystander defibrillation, and the secondary outcome is 30-day survival. Data on patients who had an OHCA will be collected through the Danish Cardiac Arrest Registry.

ETHICS AND DISSEMINATION

Approval to store OHCA data has been granted from the Legal Office, Capital Region of Denmark (j.nr: 2012-58-0004, VD-2018-28, I-Suite no: 6222, and P-2021-670). In Denmark, formal approval from the ethics committee is only obtainable when the study regards testing medicine or medical equipment on humans or using genome or diagnostic imagine as data source. The Ethics Committee of the Capital Region of Denmark has evaluated the trial and waived formal approval unnecessary (H-19037170). Results will be published in peer-reviewed papers and shared with funders, stakeholders, and housing organisations through summaries and presentations.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04446585).

Provision of bystander CPR for out-of-hospital cardiac arrest in the Middle East: a retrospective gender-based analysis

BACKGROUND

Previous studies conducted in North America, Europe, and East Asia (Liu et al., EClinicalMedicine 44:101293, 2022; Matsui et al., JAMA Netw Open 2:e195111, 2019; Awad et al., J Am Coll Emerg Physicians Open 4:e12957, 2023; Yoon et al., Prehosp Emerg Care :1-7, 2022) reported gender disparities in the provision of bystander CPR for patients with out-of-hospital cardiac arrest (OHCA). However, it remains unknown whether similar disparities exist in the Middle Eastern and Gulf regions. The primary objective of this study is to evaluate gender differences in the provision of bystander CPR for patients with OHCA in Qatar.

METHODS

Retrospective analysis of data obtained from Hamad Medical Corporation OHCA registry in the State of Qatar (2016-2022). We included adults with non-traumatic and EMS-attended OHCA. We used multilevel logistic regression to examine the association between gender and provision of bystander CPR.

RESULTS

In total, 4283 patients were included. Of those, 3414 (79.7%) were males, 1639 (38.3%) arrested in public locations, and 1463 (34.2%) received bystander CPR. Unadjusted comparisons showed that females were significantly older than males (mean age: 62.2 vs. 52.7). Females had a lower proportion of OHCA occurring in public locations (15.1% vs. 44.2%) and a lower proportion of shockable rhythm (11.9 vs. 27.5%). Regarding the outcome variable (provision of bystander CPR), the unadjusted analysis showed that the proportion of females who received bystander CPR was lower than that of males (29.2% vs. 35.4%, p < 0.001). However, after adjustment, we found no significant difference in provision of bystander CPR by gender (adjusted OR female vs. male 0.99, 95% CI 0.84-1.20, p = 0.97). In the subgroup who arrested in public locations, the analysis revealed females had greater odds of receiving bystander CPR (adjusted OR female vs. male 1.47, 95% CI 1.10-1.82, p = 0.04).

CONCLUSIONS

Overall, bystander CPR was less common in female gender; after adjustment for other covariates, including arrest location, we found no significant gender differences in provision of bystander CPR. We also observed that females were found to have a lower incidence of cardiac arrest in public locations. Nevertheless, if females were to experience cardiac arrest in a public location, they would be more likely to receive CPR. Further research is required to explain the observed differences in provision of bystander CPR.

The Lancet Commission to reduce the global burden of sudden cardiac death: a call for multidisciplinary action

Despite major advancements in cardiovascular medicine, sudden cardiac death (SCD) continues to be an enormous medical and societal challenge, claiming millions of lives every year. Efforts to prevent SCD are hampered by imperfect risk prediction and inadequate solutions to specifically address arrhythmogenesis. Although resuscitation strategies have witnessed substantial evolution, there is a need to strengthen the organisation of community interventions and emergency medical systems across varied locations and health-care structures. With all the technological and medical advances of the 21st century, the fact that survival from sudden cardiac arrest (SCA) remains lower than 10% in most parts of the world is unacceptable. Recognising this urgent need, the Lancet Commission on SCD was constituted, bringing together 30 international experts in varied disciplines. Consistent progress in tackling SCD will require a completely revamped approach to SCD prevention, with wide-sweeping policy changes that will empower the development of both governmental and community-based programmes to maximise survival from SCA, and to comprehensively attend to survivors and decedents' families after the event. International collaborative efforts that maximally leverage and connect the expertise of various research organisations will need to be prioritised to properly address identified gaps. The Commission places substantial emphasis on the need to develop a multidisciplinary strategy that encompasses all aspects of SCD prevention and treatment. The Commission provides a critical assessment of the current scientific efforts in the field, and puts forth key recommendations to challenge, activate, and intensify efforts by both the scientific and global community with new directions, research, and innovation to reduce the burden of SCD worldwide.

Out of sight - Out of mind? The need for a professional and standardized peri-mission first responder support model

First responders are an essential part of the chain (-mail) of survival as they bridge and reduce the time to first chest compressions and defibrillation substantially. However, in the peri-mission phase before and after being sent to a cardiac arrest, these first responders are in danger of being forgotten and taken for granted, and the potential psychological impact has to be remembered. We propose a standardized first responder support system (FRSS) that needs to ensure that first responders are valued and cared for in terms of psychological safety and continuing motivation. This multi-tiered program should involve tailored education and standardized debriefing, as well as actively seeking contact with the first responders after their missions to facilitate potentially needed professional psychological support.

Racial and ethnic disparities in the provision of bystander CPR after witnessed out-of-hospital cardiac arrest in the United States

OBJECTIVE

To evaluate the association between race/ethnicity and the odds of receiving bystander cardiopulmonary resuscitation (bCPR) after witnessed out-of-hospital cardiac arrest (OHCA).

METHODS

For this cross-sectional retrospective study, data were obtained from the National Emergency Medical Services Information System database for adults (≥18 years) with a witnessed non-traumatic OHCA in the year 2021. Patients were separated into two groups including Black/Hispanic and White. The primary outcome was the odds of receiving bCPR. We excluded traumatic etiology, do-not-resuscitate orders, and arrest in a healthcare facility or wilderness location. Multiple logistic regression controlling for known covariates was utilized and analyses were stratified by public versus non-public location, median household income, and rural, suburban, or urban setting.

RESULTS

A total of 64,007 witnessed OHCAs were included. When compared to White, the Black/Hispanic group were younger (62 vs 67 years) and more often female (40% vs 33%), in neighborhoods with the lowest median household income (31% vs 13%) and in an urban setting (92% vs 80%). Overall, bystander CPR rates were 60% and 67% for the Black/Hispanic and White groups, respectively. Multiple logistic regression stratified by OHCA location found that the Black/Hispanic group had a decreased odds of receiving bCPR compared to the White group both in the home (adjusted OR [aOR] 0.77; 95% CI 0.74-0.81) and in public (aOR 0.69; 95% CI 0.64-0.76). This difference persisted throughout neighborhoods of different socioeconomic status and across the rural-urban spectrum.

CONCLUSIONS

Racial/ethnic disparities exist for Black and Hispanic persons in the odds of receiving bCPR after a witnessed non-traumatic OHCA regardless of public or private setting, neighborhood income level, or population density.

Pre-Arrival Care of the Out-of-Hospital Cardiac Arrest Victim

Lay rescuers play a pivotal role in the recognition and initial management of out-of-hospital cardiac arrest. The provision of timely pre-arrival care by lay responders, including cardiopulmonary resuscitation and the use of automated external defibrillator before emergency medical service arrival, is important link in the chain of survival and has been shown to improve outcomes from cardiac arrest. Although physicians are not directly involved in bystander response to cardiac arrest, they play a key role in emphasizing the importance of bystander interventions.

Follow-up on volunteer responders dispatched for out-of-hospital cardiac arrests: Addressing the psychological and physical impact

Introduction

Smartphone technology is increasingly used to engage lay people as volunteer responders in resuscitation attempts. Attention has recently been drawn to how resuscitation attempts may impact bystanders. Attempting resuscitation in out-of-hospital cardiac arrests (OHCA) may be an overwhelming experience and, in some cases, difficult to cope with. We developed a volunteer responder follow-up program to systematically measure the psychological and physical impact on volunteer responders dispatched for OHCAs.

Methods and Results

The nationwide Danish volunteer responder program dispatches volunteer responders for presumed cardiac arrests. 90 min after notification of a potential nearby cardiac arrest, all volunteer responders receive a survey, and are asked to self-report their mental state of mind after the event. The volunteer responders are also asked to disclose any physical injury they sustained in relation to the event. Volunteer responders who report severe mental effects are offered a defusing conversation by a trained nurse. Between 1 September 2017 and 31 December 2022, the Danish volunteer responder program has alerted 177,866 volunteer responders for 10,819 presumed cardiac arrest alerts. Of 177,866 alerted volunteers responders, 62,711 accepted the alarm. In the same period, 7,317 cancelled their registration. From January 2019 to 31 December 31 2022, a total of 535 volunteer responders were offered a defusing consultation.

Conclusion

The Danish volunteer responder follow-up program is carried out to assess the psychological and physical risks of responding to a suspected OHCA. We suggest a survey-based method for systematic screening of volunteer responders that allow volunteer responders to report any physical injury or need of psychological follow-up. The person providing defusing should be a trained and experienced healthcare professional.

Temperature Control After Cardiac Arrest: A Narrative Review

Cardiac arrest (CA) is a critical public health issue affecting more than half a million Americans annually. The main determinant of outcome post-CA is hypoxic-ischemic brain injury (HIBI), and temperature control is currently the only evidence-based, guideline-recommended intervention targeting secondary brain injury. Temperature control is a key component of a post-CA care bundle; however, conflicting evidence challenges its wide implementation across the vastly heterogeneous population of CA survivors. Here, we critically appraise the available literature on temperature control in HIBI, detail how the evidence has been integrated into clinical practice, and highlight the complications associated with its use and the timing of neuroprognostication after CA. Future clinical trials evaluating different temperature targets, rates of rewarming, duration of cooling, and identifying which patient phenotype benefits from different temperature control methods are needed to address these prevailing knowledge gaps.

Developments in Post-Resuscitation Care for Out-of-Hospital Cardiac Arrests in Adults-A Narrative Review

This review focuses on current developments in post-resuscitation care for adults with an out-of-hospital cardiac arrest (OHCA). As the incidence of OHCA is high and with a low percentage of survival, it remains a challenge to treat those who survive the initial phase and regain spontaneous circulation. Early titration of oxygen in the out-of-hospital phase is not associated with increased survival and should be avoided. Once the patient is admitted, the oxygen fraction can be reduced. To maintain an adequate blood pressure and urine output, noradrenaline is the preferred agent over adrenaline. A higher blood pressure target is not associated with higher rates of good neurological survival. Early neuro-prognostication remains a challenge, and prognostication bundles should be used. Established bundles could be extended by novel biomarkers and methods in the upcoming years. Whole blood transcriptome analysis has shown to reliably predict neurological survival in two feasibility studies. This needs further investigation in larger cohorts.

Three-year trends in out-of-hospital cardiac arrest across the world: second report from the International Liaison Committee on Resuscitation (ILCOR)

BACKGROUND

The International Liaison Committee on Resuscitation (ILCOR) Research and Registries Working Group previously reported data on systems of care and outcomes of out-of-hospital cardiac arrest (OHCA) in 2015 from 16 national and regional registries. To describe the temporal trends with updated data on OHCA, we report the characteristics of OHCA from 2015 through 2017.

METHODS

We invited national and regional population-based OHCA registries for voluntary participation and included emergency medical services (EMS)-treated OHCA. We collected descriptive summary data of core elements of the latest Utstein style recommendation during 2016 and 2017 at each registry. For registries that participated in the previous 2015 report, we also extracted the 2015 data.

RESULTS

Eleven national registries in North America, Europe, Asia, and Oceania, and 4 regional registries in Europe were included in this report. Across registries, the estimated annual incidence of EMS-treated OHCA was 30.0-97.1 individuals per 100,000 population in 2015, 36.4-97.3 in 2016, and 40.8-100.2 in 2017. The provision of bystander cardiopulmonary resuscitation (CPR) varied from 37.2% to 79.0% in 2015, from 2.9% to 78.4% in 2016, and from 4.1% to 80.3% in 2017. Survival to hospital discharge or 30-day survival for EMS-treated OHCA ranged from 5.2% to 15.7% in 2015, from 6.2% to 15.8% in 2016, and from 4.6% to 16.4% in 2017.

CONCLUSION

We observed an upward temporal trend in provision of bystander CPR in most registries. Although some registries showed favourable temporal trends in survival, less than half of registries in our study demonstrated such a trend.

Assessing the weak links - Necessity and impact of regional cardiac arrest awareness campaigns for laypersons

Introduction

Public knowledge of out-of-hospital cardiac arrest (OHCA), and initiation of basic life support (BLS) is crucial to increase survival in OHCA.

Methods

The study analysed the knowledge and willingness to perform BLS of laypersons passing an AED at a public train station. Interviewees were recruited at two time points before and after a four year-long structured regional awareness campaign, which focused on call, compress, shock in a mid-size European city (270,000 inhabitants). Complete BLS was defined as multiple responses for call for help; initiation of chest compressions; and usage of an AED, without mentioning recovery position. Minimal BLS was defined as call for help and initiation of chest compressions.

Results

A total of 784 persons were interviewed, 257 at baseline and 527 post-campaign. Confronted with a fictional OHCA, at baseline 8.5% of the interviewees spontaneously mentioned actions for complete BLS and 17.9% post-campaign (p = 0.009). An even larger increase in knowledge was seen in minimal BLS (34.6% vs 60.6%, p < 0.001).

Conclusion

After a regional cardiac arrest awareness campaign, we found an increase in knowledge of BLS actions in the lay public. However, our investigation revealed severe gaps in BLS knowledge, possibly resulting in weak first links of the chain of survival.