Improving survival from sudden cardiac arrest: the "chain of survival" concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association

Assessing with CARE: an innovative method of testing the approach and casualty assessment components of basic life support, using video recording

The resuscitation community is now moving towards a set of basic life support guidelines but different countries and training centres have their own individual methods of instruction. It would be advantageous if a universal testing method were available to facilitate intercentre comparison. This could lead to an international course which had been rigorously assessed and evaluated. Taking this as a starting point, the Cardiff Assessment of Response and Evaluation (CARE) was developed. CARE is an innovative assessment technique using video recording for testing the preliminary steps of life support as outlined by the European Resuscitation Council. The assessment was validated by testing 67 members of the public who had been trained in cardiopulmonary resuscitation, 27 shortly after instruction and 40 between 6 and 18 months after instruction. All subjects were tested without prior warning and video recorded for independent scoring by two researchers and a paramedic training officer. Scores were compared using the k correlation which showed a high level of agreement between observers. Video recording and marking using the CARE schedule and guidelines is a reliable method for assessing the preliminary steps in life support.

Predicting survival from out-of-hospital cardiac arrest: a multivariate analysis

From 954 attempts to resuscitate patients from out-of-hospital cardiac arrest two datasets were derived, namely 861 cases of cardiac arrest and 906 cases of either cardiac or primary respiratory arrest. For each dataset, multivariate analysis was performed by fitting a number of explanatory variables with respect to the outcomes of admission to hospital and discharge home in logistic regression models. There were numerous interactions between these variables. Being conscious at the time of the arrival of the ambulance crew and subsequently having cardiac arrest strongly predicted survival, as did both the presence of a witness to the arrest and the initiation of cardiopulmonary resuscitation (CPR) by a bystander; this latter effect was a marker for early CPR. The strongest predictor of a poor outcome was delay to CPR or delay to advanced cardiac life support.

Community cardiac awareness teaching in a rural area: the potential for a health promotion message

Little information has been published on the uptake of cardiopulmonary resuscitation (CPR) training in rural areas or on the potential to associate a health promotion message with skills training. This paper describes CPR instructor and community training programmes in Ireland. Public interest in these programmes has been strongest in rural areas, which have constituted the main focus of activity to date. High-quality training of lay instructors has been a specific target of the programmes, which have included a significant health promotion message. In the pilot rural area, almost 2% of adults aged between 15 and 64 years attended a course during the first year of operation. However, the self-reported risk factor profile of participants suggests significant under-estimation of risk factors such as obesity, hypertension or raised blood cholesterol. While general population teaching programmes can attract large numbers of participants, even in isolated rural areas, the perceived relevance of an associated health promotion message may be very low.

Managed care organizations: a link in the chain of survival?

Managed care organizations (MCOs) have proliferated throughout the United States. Interaction by patients, physicians, and emergency medical services systems with MCOs is evolving. Although MCOs have had some notable successes in reducing health care expenditures, the way in which MCO enrollees gain access to emergency medical care remains a contested issue. We present the cases of two patients who died after they delayed calling 911 in keeping with the rules of their MCO.

Bystander-initiated cardiopulmonary resuscitation out-of-hospital. A first description of the bystanders and their experiences

At present there are about 1 million trained cardiopulmonary resuscitation (CPR) rescuers in Sweden. CPR out-of-hospital is initiated about 2000 times a year in Sweden. However, very little is known about the bystanders' experiences and reactions. The aim of this study was to describe bystander-initiated CPR, the circumstances, the bystander and his experiences. All CPR bystanders in Sweden who reported their resuscitation attempts between 1990 and 1994 were approached with a phone interview and a postal questionnaire, resulting in 742 questionnaires. Bystander-initiated CPR most frequently took place in public places such as the street. The rescuer most frequently had problems with mouth-to-mouth ventilation (20%) and vomiting (18%). More than half (53%) of the rescuers experienced CPR without problems. Ninety-two percent of the bystanders had no hesitation because of fear of contracting the acquired immunodeficiency syndrome (AIDS) virus. Ninety-three percent of the rescuers regarded their intervention as a mainly positive experience. Of 425 interviewed rescuers, 99.5% were prepared to start CPR again.

A comparison of prolonged manual and mechanical external chest compression after cardiac arrest in dogs

The effects of manual and a new mechanical chest compression device (Heartsaver 2000) during prolonged CPR with respect to haemodynamics and outcome were tested in a prospective, randomized, controlled experimental trial during ventricular fibrillation in 12 dogs of 9-13 kg body weight after 1 min of cardiac arrest. During the first 10 min of CPR the dogs were resuscitated according to the Basic Life Support (BLS) algorithm, followed by 20 min of Advanced Life Support (ALS) algorithm. After 30 min of CPR both manual and mechanical CPR groups were resuscitated following a standardized ALS protocol. During CPR, coronary perfusion pressure and end tidal CO2 were greater with mechanical CPR. All animals were successfully resuscitated and neurological deficit scores were not different. The CPR trauma score was less in the mechanical group. Mechanical external chest compression provided better haemodynamics than the manual technique, though outcome did not differ. Both optimally performed manual and mechanical techniques produce flow sufficient to maintain organ viability for 30 min of CPR after a 1 min arrest interval.

Cardiopulmonary resuscitation training for UK undergraduate dental students

Cardiopulmonary resuscitation (CPR) is a vital skill which must be mastered by all health care professionals. The General Dental Council recommends that it is taught to all UK dental undergraduates. This study was done to elicit how many schools teach aspects of Basic and Advanced Life Support to their students, how often and whether they assess their students. All UK schools teach Basic Life Support (BLS) at least once, but a lower proportion assess their students formally and only three schools teach BLS in each year of the course. Only 64% (9/14) of respondents thought their students received enough training to be able to cope with the initial stages of an emergency on their own. Thus, although the level of BLS training is probably acceptable at present, further improvement of CPR training in UK Dental Schools is advisable.

Future directions for resuscitation research. III. External cardiopulmonary resuscitation advanced life support

This discussion about advanced cardiac life support (ACLS) reflects disappointment with the over 50% of out-of-hospital cardiopulmonary resuscitation (CPR) attempts that fail to achieve restoration of spontaneous circulation (ROSC). Hospital discharge rates are equally poor for in-hospital CPR attempts outside special care units. Early bystander CPR and early defibrillation (manual, semi-automatic or automatic) are the most effective methods for achieving ROSC from ventricular fibrillation (VF). Automated external defibrillation (AED), which is effective in the hands of first responders in the out-of-hospital setting, should also be used and evaluated in hospitals, inside and outside of special care units. The first countershock is most important. Biphasic waveforms seem to have advantages over monophasic ones. Tracheal intubation has obvious efficacy when the airway is threatened. Scientific documentation of specific types, doses, and timing of drug treatments (epinephrine, bicarbonate, lidocaine, bretylium) are weak. Clinical trials have failed so far to document anything statistically but a breakthrough effect. Interactions between catecholamines and buffers need further exploration. A major cause of unsuccessful attempts at ROSC is the underlying disease, which present ACLS guidelines do not consider adequately. Early thrombolysis and early coronary revascularization procedures should also be considered for selected victims of sudden cardiac death. Emergency cardiopulmonary bypass (CPB) could be a breakthrough measure, but cannot be initiated rapidly enough in the field due to technical limitations. Open-chest CPR by ambulance physicians deserves further trials. In searches for causes of VF, neurocardiology gives clues for new directions. Fibrillation and defibrillation thresholds are influenced by the peripheral sympathetic and parasympathetic nervous systems and impulses from the frontal cerebral cortex. CPR for cardiac arrest of the mother in advanced pregnancy requires modifications and outcome data. Until more recognizable critical factors for ROSC are identified, titrated sequencing of ACLS measures, based on physiologic rationale and sound judgement, rather than rigid standards, gives the best chance for achieving survival with good cerebral function.

Chronic memory impairment after cardiac arrest outside hospital

OBJECTIVES

To evaluate the nature, prevalence, and severity of chronic memory deficit in patients resuscitated after cardiac arrest outside hospital and to determine whether such deficits are related to duration of cardiac arrest.

DESIGN

Case-control study.

SUBJECTS

35 survivors of cardiac arrest outside hospital and 35 controls matched for age and sex who had had acute myocardial infarction without cardiac arrest.

MAIN OUTCOME MEASURES

Subjects assessed at least two months after index event for affective state (hospital anxiety and depression scale), premorbid intelligence (national adult reading test), short term recall (digit recall test), and episodic long term memory (Rivermead behavioural memory test).

RESULTS

Cases and controls showed no difference in short term recall. Cases scored lower on Rivermead test than controls (mean (SD) score out of 24 points: 17.4 (5.4) v 21.8 (2.0), P < 0.001), particularly in subtests relating to verbal and spatial memory. Moderate or severe impairment was found in 37% of cases and in no controls. Severity of impairment of memory correlated significantly with measures of duration of cardiac arrest. This deficit was not significantly associated with subjects' age, interval from index event to assessment, occupation, measures of comorbidity, social deprivation, anxiety or depression scores, or estimated premorbid intelligence.

CONCLUSIONS

Clinically important impairment of memory was common after cardiac arrest outside hospital. Improvement in response times of emergency services could reduce the severity of such deficits. With an increasing numbers of people expected to survive cardiac arrest outside hospital, rehabilitation of those with memory deficit merits specific attention.

The role of nurses in cardiopulmonary resuscitation and defibrillation

Cardiac [corrected] arrest outcome studies have identified early defibrillation (among other variables) as a strong predictor of survival--with the emphasis placed on minimal delay between arrest and 'shock'. Nurses play a key role in the management of in-hospital cardiac arrest. Often they are first on the scene of an arrest--initiating cardiopulmonary resuscitation (CPR) as well as summoning assistance from the 'advanced life support'/'arrest' team. Thus it is argued that nurses should be willing (and able) to perform defibrillation when required. Notwithstanding this, the community has an expectation (rightly or wrongly) that all nurses are able to appropriately manage a collapse situation. However, research clearly demonstrates that not all nurses are competent in CPR. There is obviously a mismatch between community expectations and reality, which nursing needs to address. Nurses can contribute to the prevention of cardiac arrest in the community by promoting the importance of seeking medical care in the event of chest pain. Furthermore, skilled clinical assessment and recognition of the prodromes of cardiorespiratory collapse may reduce the incidence of in-hospital cardiac arrests.

Cost-effectiveness analysis of potential improvements to emergency medical services for victims of out-of-hospital cardiac arrest

STUDY OBJECTIVE

To measure the incremental cost-effectiveness of various improvements to emergency medical services (EMS) systems aimed at increasing survival after out-of-hospital cardiac arrest.

METHODS

We performed cost-effectiveness analysis based on (1) metaanalysis of effectiveness of the various EMS systems, (2) costing of each component of EMS systems, (3) modeling of the relationship between the proportion of cardiac arrest victims who receive CPR and the proportion of individuals trained, (4) modeling of the relationship between response time interval and the characteristics of the EMS system, (5) measurement of quality of life, and (6) decision analysis to combine the results of the first five components.

RESULTS

The incremental cost-effectiveness ratio for a 48-second improvement in mean response time in a one-tier EMS system yielded by the addition of more EMS providers was $368,000 per quality-adjusted life year (QALY). For improved response time in a two-tier EMS system by the addition of more basic life support (BLS)/BLS-defibrillator (BLS-D) providers to the first tier, the ratio was $53,000 per QALY with pump vehicles or $159,000 per QALY with ambulances. Change from a one-tier EMS to a two-tier EMS system by the addition of initial BLS/BLS-D providers in pump vehicles as the first tier was associated with a cost per QALY of $40,000. Change from one-tier EMS to two-tier EMS by the addition of initial BLS/BLS-D providers in ambulances as the first tier was associated with a cost per QALY of $94,000.

CONCLUSION

The most attractive options in terms of incremental cost-effectiveness were improved response time in a two-tier EMS system or change from a one-tier to a two-tier EMS system. Future research should be directed toward identification of the costs of instituting the first tier of a two-tier EMS system and identification of cost-effective methods of improving response time.

Effectiveness of emergency medical services for victims of out-of-hospital cardiac arrest: a metaanalysis

STUDY OBJECTIVE

To determine the relative effectiveness of differences in response time interval, proportion of bystander CPR, and type and tier of emergency medical services (EMS) system on survival after out of hospital cardiac arrest.

METHODS

We performed a comprehensive literature search, excluding EMS systems other than those of interest (systems of interest were those comprising one tier with providers of basic life support [BLS] or advanced life support [ALS] and those comprising two tiers with providers of BLS or BLS-defibrillation followed by ALS), patient population of fewer than 100 cardiac arrests, studies in which we could not determine the total number of arrests of presumed cardiac origin, and studies lacking data on survival to hospital discharge. Metaanalysis using generalized linear model with dispersion estimation for random effects was then performed.

RESULTS

Increased survival to hospital discharge was significantly associated with tier (P < .01), response time interval (P < .01), and bystander CPR (P = .04). A significant interaction was detected between response time interval and bystander CPR (P = .02). For the studies analyzed, survival was 5.2% in a one-tier EMS system or 10.5% in a two-tier EMS system. A 1-minute decrease in mean response time interval was associated with absolute increases in survival rates of .4% and .7% in a one-tier and two-tier EMS systems, respectively.

CONCLUSION

Increased survival to hospital discharge may be associated with decreased response time interval and with the use of a two-tier EMS system as opposed to a one-tier system. The data available for this analysis were suboptimal. Policymakers need more methodologically rigorous research to have more reliable and valid estimates of the effectiveness of different EMS systems.

Can regional variation in "avoidable" mortality be explained by deaths outside hospital? A study from Sweden, 1987-90

STUDY OBJECTIVE

This study aimed to calculate the proportion of deaths outside hospital in Sweden for some conditions for which the acute medical management may be important to the outcome and to analyse whether the proportion of deaths outside hospital can explain regional variations in mortality from these causes of death.

DESIGN

The place of death was registered on all death certificates in Sweden during the period 1987-90. The proportion of deaths outside hospital was calculated at the national level for selected causes of death. Variation in cause-specific mortality among the 26 administrative health areas in Sweden was analysed. Death rate ratios were calculated with standardisation for age and sex using the national rate as standard. The correlation between the proportion of deaths outside hospital in each health area and the cause specific mortality irrespective of place of death was calculated. For areas with a significantly high death rate the ratios for mortality outside hospital as well as in hospital were analysed in order to decide which component of mortality represented a high mortality risk.

SETTING AND PARTICIPANTS

All death registration in Swedish citizens and other residents in Sweden aged under 70 years between 1987 and 1990 which gave diabetes, asthma, ischaemic heart disease, cerebrovascular diseases, or ulcer of the stomach or duodenum as the underlying cause of death.

MAIN RESULTS

For asthma (58%) and ischaemic heart disease (54%), most deaths occurred outside hospital. For most causes of death, however, no correlation was found among the health areas between the proportion of deaths outside hospital and the SMR for mortality irrespective of the place of death. A high death rate was associated with a high proportion of deaths outside hospital, for diabetes in one area in the north of Sweden (Norrbotten) and for ulcer of the stomach and duodenum in one large municipality (Göteborg).

CONCLUSIONS

The high proportion of deaths outside hospital at the national level for some of the conditions studied suggests that in-depth studies of the process preceding death and the functioning of medical care are needed. In most cases, however, no evidence was found that regional variation in mortality could be explained by death outside hospital. The results for diabetes in Norbotten and ulcer of stomach and duodenum in Göteborg indicate that in-depth studies on the quality of care are required.

End-tidal carbon dioxide during cardiopulmonary resuscitation in humans presenting mostly with asystole: a predictor of outcome

OBJECTIVE

To determine whether continuous semiquantitative assessment of end-tidal CO2 could provide a highly sensitive predictor of return of spontaneous circulation during cardiopulmonary resuscitation (CPR).

DESIGN

Prospective, clinical study.

SETTING

Prehospital CPR.

PATIENTS

One hundred twenty patients, during nontraumatic cardiac arrest.

INTERVENTIONS

End-tidal CO2 values were measured continuously after tracheal intubation, and were categorized as the initial value, and as minimal and maximal values during the first 20 mins.

MEASUREMENTS AND MAIN RESULTS

Presenting rhythm was asystole in 22 of the first 24 patients. Return of spontaneous circulation occurred in eight patients. Initial, minimal, and maximal end-tidal CO2 values were significantly (p < .01) higher in these patients than in the patients without return of spontaneous circulation. Cutoff values providing a 100% sensitivity and the highest specificity in predicting return of spontaneous circulation were found to be 10 torr for initial and maximal end-tidal CO2 values, and 2 torr for the minimal end-tidal CO2 value. The number of patients required to reject (with a risk error of <.05) the hypothesis of an actual sensitivity of < or = 90% for an observed sensitivity of 100% was found to be 95. In the second part of the study, this hypothesis was prospectively tested for initial and maximal end-tidal CO2 values in the subsequent 96 patients. Presenting cardiac rhythm was asystole in 87 patients. Return of spontaneous circulation was obtained in 30 patients. The cutoff value of 10 torr for maximal end-tidal CO2 during the first 20 mins after tracheal intubation provided an observed sensitivity of 100% in predicting return of spontaneous circulation with a specificity of 67%. This result allows rejection of the hypothesis of an actual sensitivity of < or = 90% (p = .042). By contrast, the observed sensitivity of initial end-tidal CO2 was only 87%.

CONCLUSIONS

End-tidal CO2 represents a valuable tool for monitoring patients presenting with asystole during prehospital CPR. Fluctuations in end-tidal CO2 during CPR and the utility of end-tidal CO2 in detecting return of spontaneous circulation justify its continuous measurement. In addition, a high sensitivity (>90%) in predicting return of spontaneous circulation is prospectively demonstrated using the maximal end-tidal CO2 during the first 20 mins after tracheal intubation, with a cutoff value of 10 torr. Such a prognostic indicator could be used for a more rational approach to prolonged CPR.

Left ventricular rupture following external chest compression

A case of a 62-year-old woman suffering an acute cardiac arrest during a court dispute is presented. Cardiopulmonary resuscitation was immediately started by bystanders. In hospital there were signs of intrathoracic bleeding. A left thoracotomy revealed a cardiac rupture of the left ventricle and a large pericardial tear. Intraoperative evaluation of the heart as well as postoperative enzyme levels and ECG did not indicate acute myocardial infarction. The rupture may therefore be traumatic. The cardiac rupture was sutured five hours after the initial resuscitation, and the patient discharged from the intensive care unit two days after the rupture without clinical signs of neurological injury. A precordial thump is advised before start of external chest compression. One beneficial effect may be that the ventricles empty and the risk of traumatic rupture during compression is reduced.

The ventilation/compression ratio influences the effectiveness of two rescuer advanced cardiac life support on a manikin

Time is of crucial importance during advanced cardiac life support (ACLS). Several parallel tasks have to be performed more or less simultaneously. The guidelines recommend a ventilation/ compression ratio of 1:5 in two-rescuer ACLS. This was compared with respect to time and CPR quality to an alternative method of a 2:15 ratio performed by one of the two rescuers freeing one rescuer to concentrate on other tasks than ventilation and chest compression. Seventeen paramedic students were trained in pairs in ACLS according to the European Resuscitation Council guidelines using an Ambu Mega Code trainer manikin. From a starting point of asystole paramedics were required to perform ECG analysis, intubation, i.v. access, adrenalin and atropine injection, flushing of the drug bolus before conversion to ventricular fibrillation followed by defibrillation in addition to ventilation and chest compression. Unpaired two-tailed Student t-test and the Fisher's exact test were used for statistical analysis, with a P-value less than 0.05 regarded as significant. It took significantly less time to perform successful CPR with the 2:15 ratio compared to the 1:5 ratio. The quality of the ventilations and compressions performed were not significantly different between 2:15 and 1:5 ratio. When two rescuers are performing ACLS, the 2:15 ratio method appears to be time saving vs. the 1:5. This could potentially improve the outcome after cardiac arrest.

The effect of experience of on-site physicians on survival from prehospital cardiac arrest

Outcome from prehospital cardiac arrest was studied 1 year before (Period I) and after (Period II) a reorganisation of the work and the simultaneous change of all physicians participating in the care of prehospital patients in the emergency medical service system in Helsinki. There were 444 patients during Period I and 395 patients during Period II. Resuscitation was initiated in 279 patients during Period I and in 323 patients (P < 0.001) during Period II. The number of patients with ventricular fibrillation who suffered a witnessed cardiac arrest due to presumed heart disease was 120 and 130, respectively. During Period I, 70 of these patients were successfully resuscitated and admitted to hospital, 41 (34%) survived to discharge home from hospital. Corresponding figures during Period II were 79 and 33 (25%, NS). Compared with Period I, a larger proportion of the successfully resuscitated patients either died in hospital or were discharged to an institution during Period II (P < 0.05).

Creatine kinase and creatine kinase-MB release after nontraumatic cardiac arrest

The aim of the study was to describe the course of serum creatine kinase (CK) and its MB fraction (CK-MB) in patients surviving cardiac arrest, and to identify factors influencing CK and CK-MB release. The study was set in the community of Vienna, Austria. Data concerning cardiopulmonary resuscitation, collected within a period of 33 months, were evaluated retrospectively and compared with laboratory blood investigations collected prospectively (on admission and after 6, 12, and 24 hours) in 107 adult patients surviving a witnessed cardiac arrest for 24 hours. CK and CK-MB were elevated in >75% of the patients within 24 hours. Release of CK and CK-MB was mainly associated with electrocardiographic evidence of acute myocardial infarction (AMI) cumulative energy administered during defibrillation, and duration of chest trauma by compression. The CK-MB/CK ratio was elevated in 32% of the patients. Of patients with electrocardiographic evidence of AMI, only 49% had an elevated CK-MB/CK ratio. In conclusion, the elevation in serum CK and CK-MB fraction in patients after nontraumatic cardiac arrest is a frequent finding, and is associated with ischemic myocardial injury, as well as physical trauma to the chest. This should be considered when interpreting the course of CK and CK-MB fraction for the diagnosis of AMI.

Response to cardiac arrests in a hospital setting: delays in ventilation

The outcome following a cardiac arrest is affected by the length of time that elapses before cardiopulmonary resuscitation is initiated. Only 10-15% of patients experiencing cardiac arrest in hospital settings survive to discharge. Therefore, the time between cardiac arrest and administration of cardiopulmonary resuscitation in a metropolitan hospital was examined. All cardiac and respiratory arrests that occurred in the adult non-intensive care areas of a medical center over a period of 16 months were evaluated within 12 h to determine how much time had elapsed before resuscitation was initiated, the devices utilized for initial airway management, and the outcome. To initiate ventilation, bag-valve-masks (BVMs) were used in the majority (76%) of the efforts to resuscitate while mouth-to-mask resuscitation was performed in another 18%; however, in only 37% of the codes was ventilation initiated within 1 min and in 18% ventilation was started after 3 min. Mouth-to-mask resuscitation resulted in more rapid time to onset of ventilation than BVM. In only 18% of the arrests studied was a 'lay-on' mask available in the room and utilized. In 11%, a bag-valve-mask was at the patient's bedside, and in 53% a BVM was taken from the crash cart outside the room. In 63% of the cases where using a lay-on mask was appropriate, it was either not looked for or not present in the patient's room. Also in 37% of the cases where a BVM was needed, one was not readily present because of difficulty in locating the crash cart immediately. Although initiation of cardiopulmonary resuscitation within a minute of a cardiac or respiratory arrest is the standard of care, in the non-intensive care in-patient cases surveyed, typically more than a minute elapsed, and frequently 3 or more minutes, before resuscitation was started. If the time elapsing before an arresting in-patient is ventilated can be shortened, which is easily and effectively achieved by mouth-to-mouth or mouth-to-mask resuscitation, an increase in both the survival rate and the number of good neurological outcomes should be expected.

Cardiac arrest

This article reviews the critical resuscitations necessary during prehospital and emergency department treatment of cardiac arrest. Standard therapy for cardiac arrest rhythms is presented. Novel pharmacologic agents, types of cardiopulmonary resuscitation, and circulatory-assist devices are discussed.

Automatic external defibrillators in the hospital as well?

When a cardiac arrest occurs in a non-intensive area of the hospital, the emergency response is not always adequate from the point of view of timeliness and technical quality. The aims of this study were evaluate an experimental programme to improve the CPR skills of staff operating in non-intensive areas of our general hospital and to test the usefulness of placing automatic external defibrillators (AEDs) within these areas. In the experimental phase, two AEDs were placed in 2 non-intensive wards of our hospital for 8 months. The staff of these wards received specific training in CPR and early defibrillation (CPR-D). The devices were used in 19 cases; for defibrillation in four cases of ventricular fibrillation (VF) (three patients were discharged alive from hospital), and for monitoring three supraventricular arrhythmias, one bradyarrhythmia and 11 cardiac rhythms during critical situations. In the implementation phase, four AEDs were indefinitely assigned to as many non-intensive awards. Periodical CPR-D courses and refresher exercises were run; the cardiology staff co-operated in the maintenance of the AEDs and in the registration of technical and clinical data. In the first period of this phase (9 months), AEDs were utilized in 24 cases by the ward-staff: in nine cases for VF (three patients were discharged alive from hospital) and in 15 cases for other rhythm detection in critical conditions. The number and the quality of these uses seem to confirm the favourable impact of the adoption of a more user-friendly defibrillator, such as an AED. The active co-operation between intensive and non-intensive staff was important to facilitate a quick activation of the chain of survival outside the intensive care units. We conclude that AEDs, which were developed for out-of-hospital use by non-physician operators, are suitable for use inside the hospital as well.

Teaching schoolchildren cardiopulmonary resuscitation

Forty-one children aged 11-12 years received tuition in cardiopulmonary resuscitation (CPR) and subsequently completed questionnaires to assess their theoretical knowledge and attitudes their likelihood of performing CPR. Although most children scored well on theoretical knowledge, this did not correlate with an assessment of practical ability using training manikins. In particular only one child correctly called for help after the casualty was found to be unresponsive, and none telephoned for an ambulance before starting resuscitation. These omissions have important implications for the teaching of CPR and the resulting effectiveness of community CPR programmes.

Out-of-hospital cardiac arrest due to coronary heart disease: a comparison of survival before and after the introduction of defribrillators in ambulances

OBJECTIVE

To assess the actual impact on coronary mortality of equipping ambulances with defibrillators.

DESIGN

Retrospective analysis of routine medical and legal records of all those who had a cardiac arrest attributed to coronary heart disease occurring outside hospital in a defined population before and after the introduction of Heartstart.

SETTING

City of Glasgow, North of the River Clyde, 1984 and 1990.

PATIENTS

296 and 267 men and women aged 25-64 inclusive in 1984 and 1990 respectively who had a cardiac arrest outside hospital which was attributed to coronary heart disease (International Classification of Diseases codes 410-414, ninth revision).

RESULTS

The impact on coronary mortality in 1990 of equipping ambulances with defibrillators concurred with the earlier prediction of less than 1% of all coronary deaths. The circumstances of cardiac arrest were largely unchanged; most occurred outside hospital in the victim's home and the principal witnesses were members of the victim's family. A call for help before cardiac arrest was made in very few cases and cardiopulmonary resuscitation was attempted by laypersons in less than a third of the deaths they witnessed. There was a significant increase in the number of cardiopulmonary resuscitation attempts made by ambulance crews (16% v 32%, P < 0.01). Ambulance crews, however, still attended less than half of all cases (44% and 47%).

CONCLUSION

The impact of equipping ambulances with defibrillators will remain small unless strategies are introduced that focus on improving the public's response to coronary emergencies by calling for help promptly and initiating cardiopulmonary resuscitation before the arrival of the emergency services.

Outcomes in severely ill patients transported without prehospital ALS

Because of the debate regarding the impact of advanced life support (ALS) care on the outcome of prehospital patients, we monitored the influence of lack of sophisticated prehospital treatment in cases of severe illness arriving by ambulance to the emergency department (ED). A prospective cohort study to examine and compare the outcome of trauma- and nontrauma-induced "ALS-eligible" cases in the setting of no prehospital care was carried out from August 1, 1993 through May 31, 1994. On arriving at the ED, patients meeting the criteria for ALS cases and sent by EMS public prehospital personnel were assessed for subjective and objective status and change in severity by triage nurses as well as being followed up for neurological status until discharged from the hospital. Chi-Square method was used to compare the data between two groups and P < .05 was considered statistically significant. Of 667 studied ALS cases (155 trauma and 512 nontrauma), < 20% had their condition change subjectively and < 10% had their condition change objectively; 68% of medical patients and 60% of trauma cases were discharged from the hospital (neurologically intact). However, subgroup analysis showed that objective measures worsened in transit in nearly 18% of trauma victims, a rate nearly 3 times greater than that of medical cases. Moreover, neurological outcome was particularly poor in trauma cases. These results suggest that ALS care may be valuable for severely ill trauma victims.

EMS characteristics in an Asian Metropolis

A prospective citywide cohort study was conducted from August 1, 1993, through May 31, 1994 to analyze the epidemiological characteristics of emergency medical services (EMS) in an Asian city. Of 5,459 studied cases, the leading 3 causes were trauma (49.7%), alcohol intoxication (8.6%), and altered mental status (AMS) (6.9%). Half of the studied cases needed no prehospital care and 16.4% needed advanced life support (ALS) care. Traffic accidents accounted for 68% of trauma cases. Of 897 cases requiring ALS care, the two most common causes were AMS and dead on arrival (DOA) (32.1% and 21.2% in medical group, 10.1% and 4.5% in trauma group, respectively). The response time, time on scene, and transportation time were 4.6, 4.3, and 9.4 minutes, respectively. This Oriental EMS system experienced very short prehospital times, many traffic accidents, and extremely few DOA cases. Because few patients required ALS care, an emergency medical technician-based EMS system would probably be able to handle the majority of prehospital patients.

Measuring the call-receipt-to-defibrillation interval: evaluation of prehospital methods

STUDY OBJECTIVE

Successful resuscitation of cardiac arrest depends partly on the time of first defibrillation. An accurate, practical method of measuring this time has not been devised. We attempted to determine the interval from receipt of a call by emergency medical services personnel to first defibrillation (total defibrillation interval) with synchronized clocks between computer-aided dispatch operations and an event-recording defibrillator.

DESIGN

A 7-month prospective study measuring the total defibrillation interval. An automated code summary was to be submitted for each participant.

SETTING

An urban, all-advanced life support, public utility model system.

PARTICIPANTS

All primary ventricular fibrillation patients seen during the study period.

RESULTS

Ninety-two patients met study criteria. Data are presented as median (interquartile range). The total defibrillation interval was 9.8 minutes (7.9 to 11.8 minutes). The call-receipt-to-vehicle-at-scene interval was 5.98 minutes (4.4 to 7.3 minutes). The vehicle-at-scene-to-defibrillation interval was 3.6 minutes (2.5 to 4.6 minutes).

CONCLUSION

The use of synchronized clocks in automated event-recording systems may provide a method of accurately measuring the time elapsed before defibrillation.

Ventricular fibrillation, automatic external defibrillators, and the United States Food and Drug Administration: confrontation without comprehension

More people die in the United States each day of potentially reversible VF than of any other cause of death, reversible or not. Early defibrillation is the definitive treatment. Automated external defibrillation is a proven technology now confirmed to have saved thousands of lives. As with all medical devices and technology, perfection is not possible. Some problems, such as those represented by the two cases discussed in this article, are inevitable and acceptable and give little cause for alarm. One would not stop penicillin from being manufactured and distributed because of a sudden, unexpected allergic reaction in one patient (error of commission) or an unexpected resistant organism in another (error of omission). The FDA must understand that AEDs, even if they are imperfect, are not anywhere near as dangerous as no defibrillator at all. AEDs have finally allowed many EMS systems to achieve early defibrillation. Discontinuing use of AEDs or closing AED manufacturers could mean a significant number of lives lost unnecessarily. Therefore EMS agencies planning to implement early-defibrillation programs should continue with such plans. Why the agents of an important federal regulatory agency have singled out this technology for an intense review puzzles many observers in the medical-device field. Two meetings have been hosted by officials of the FDA to discuss the continuing concern the FDA officials have expressed over automated defibrillation technology. These meetings included representatives from the AHA, the American College of Cardiology, ACEP, defibrillator manufacturers, and other interested organizations. The FDA leadership has repeatedly focused on data acquired through the FDA Medical Device Reporting systems. Congress requires the FDA to investigate reports of problems with "critical medical devices." Because the indication for the use of a defibrillator is cardiac arrest, there will inevitably be a high association between defibrillator use and patient deaths. FDA personnel may view such reports of device problems in association with patient deaths as evidence that an intrinsically flawed technology has reached the marketplace without rigorous testing and evaluation. From the clinician's perspective, however, these reports represent a small numerator over a huge denominator of daily, lifesaving clinical use. The non-FDA participants at the two meetings have stated that the FDA complaints appear to be random and reveal a lack of understanding of AED technology.(ABSTRACT TRUNCATED AT 400 WORDS)

Organizing and implementing a hospital-wide first-responder automated external defibrillation program: strengthening the in-hospital chain of survival

First-responder automated external defibrillation (AED) in the hospital is consistent with the American Heart Association's (AHA) early defibrillation standard or care. With trained personnel and automated external defibrillators immediately available, early defibrillation should have a greater impact on survival than early cardiopulmonary resuscitation (CPR). Therefore, in our hospitals we modified basic life support to include automated external defibrillation (BLS-AED) for all personnel who are expected to respond to a cardiac arrest, with rapid defibrillation taking priority over CPR. We describe how we organized and implemented this hospital-wide first-responder BLS-AED program. Planning the process includes gaining support from key leaders who are responsible for resuscitation practice, and identifying the target audience of the training program. Hospital unit needs for AED or conventional defibrillation and equipment must be identified, the training program developed, and existing policies and procedures modified. Several barriers to implementation may exist. Education about the efficacy and safety of AED and experience once the BLS-AED program is in place can overcome attitudes and bias. Concerns about the cost of equipment and training must be addressed. Program evaluation may include patient issues such as measuring the time to the first defibrillation and patient outcome; as well as training and retention issues.

In-hospital mortality after out-of-hospital cardiac arrest

In-hospital management of out-of-hospital cardiac arrest is complicated by uncertainty about prognosis and the need to identify markers of adverse outcome in individuals surviving initial resuscitation. We sought to identify factors that predict in-hospital death among patients who initially survive out-of-hospital cardiac arrest. We investigated 346 consecutive cases of out-of-hospital cardiac arrest received by a single centre in Edinburgh, UK (270 cases examined retrospectively, 76 prospectively). Of the retrospective cohort, 246 cases were thought to be of cardiac origin. There were associations between in-hospital mortality and pre-arrest variables, resuscitation variables, and factors measured during admission. Crew-witnessed arrests were associated with low mortality; arrest rhythm (p < 0.001), resuscitation by a health professional (p < 0.05), conscious level on admission (p < 0.001), and requirement for ventilation (p < 0.05) independently predicted in-hospital mortality. A weighted prognostic scoring system based on three of these variables accurately predicted the likelihood of in-hospital death in the prospective test group. Further assessment of conscious level during admission with the Glasgow coma score predicted mortality rates in the study population, but coma did not predict a hopeless prognosis in individual cases unless it persisted for 72 h or more. Accurate prognostic assessment of out-of-hospital cardiac arrest survivors can be made from information available on admission. Of factors that independently predicted outcome, the skill of the resuscitator is most readily modified. This suggests that public training in resuscitation may reduce mortality rates.

Emergency medical service systems research: problems of the past, challenges of the future

Out-of-hospital emergency care was designed around the concept of a system of interrelated events that combine to offer a patient the best care possible outside the hospital. However, in contrast to the actual operations of emergency medical service (EMS) systems, research has not typically used systems-based models as the method for evaluation. In this discussion we outline the weaknesses of component-based research models in EMS evaluation and attempt to provide a "systems-analysis" framework that can be used for future research. Incorporation of this multidiscipline approach into EMS research is essential if there is to be any hope of finding answers to many of the important questions that remain in the arena of out-of-hospital health care.

Effects of prehospital care on outcome in patients with cardiac illness

STUDY OBJECTIVE

To compare outcomes of patients with acute cardiac illness transported by ambulance for whom prehospital care was provided by emergency medical technician-paramedics (EMT-Ps) or EMTs trained in defibrillation (EMT-Ds).

DESIGN

A prospective chart review carried out over 3.5 years.

SETTING

The Hamilton-Wentworth region of Ontario, Canada, which covers 1,136 km2 and includes five receiving hospitals.

PARTICIPANTS

We prospectively identified 8,720 potentially eligible patients from approximately 30,000 who presented to the ambulance service. We reviewed hospital charts to confirm eligibility. The group of 8,720 patients yielded 3,066 patients with acute cardiac illness who met all other eligibility requirements. We excluded patients in cardiac arrest.

RESULTS

Incidence of myocardial infarction (MI), length of hospital stay, and mortality were evaluated. Analysis was performed with chi 2 tests for association, linear regression, and logistic regression. Of the eligible patients who received prehospital EMS care, 783 sustained MIs. The proportions of people discharged alive with the diagnosis of MI did not differ between crew types (P = .16). Average hospital stay was 13 days in both groups for patients with the discharge diagnosis of MI; hospital stay ranged from 9 (EMT-D) to 11 days (EMT-P) for any patient with a discharge diagnosis other than MI. These values were statistically similar. The odds ratio of having had an MI after treatment by an EMT-D crew was 1.02 (95% confidence interval, .86 to 1.21) compared with that for treatment by an EMT-P crew.

CONCLUSIONS

In an urban setting with short (less than 10 minutes) average transport times, the availability of prehospital paramedic care does not affect occurrence of MI, length of hospital stay, or mortality of patients presenting to the EMS system with cardiac illness.

Effect of out-of-hospital defibrillation by basic life support providers on cardiac arrest mortality: a metaanalysis

STUDY OBJECTIVE

Although some studies demonstrate otherwise, we hypothesized that metaanalysis would demonstrate a reduction in the relative risk of mortality when basic life support (BLS) providers can defibrillate out-of-hospital cardiac arrest patients.

DESIGN

Metaanalysis of studies meeting the following criteria: single-tier or two-tier emergency medical service (EMS) system, survival to hospital discharge for patients in ventricular fibrillation, and manual and/or automatic external defibrillators. The alpha error rate was .05.

RESULTS

Seven trials qualified for metaanalysis. Across all trials, the risk of mortality for BLS care with defibrillation versus that without was .915 (P = .0003). Separate subset analyses of single-tier and two-tier EMS systems demonstrated similar results.

CONCLUSION

BLS defibrillation can reduce the relative risk of death for out-of-hospital cardiac arrest victims in ventricular fibrillation. Weaknesses in individual study designs and regional clustering limit the strength of this metaanalysis and conclusion.

Paramedics and technicians are equally successful at managing cardiac arrest outside hospital

OBJECTIVE

To examine the effect on survival of treatment by ambulance paramedics and ambulance technicians after cardiac arrest outside hospital.

DESIGN

Prospective study over two years from 1 April 1992 to 31 March 1994.

SETTING

Accident and emergency department of university teaching hospital.

SUBJECTS

502 consecutive adult patients with out of hospital cardiopulmonary arrest of cardiac origin.

INTERVENTIONS

Treatment by ambulance technicians or paramedics both equipped with semiautomatic defibrillators.

MAIN OUTCOME MEASURES

Rate of return of spontaneous circulation, hospital admission, and survival to hospital discharge.

RESULTS

Rates of return of spontaneous circulation, hospital admission, and survival to hospital discharge were not significantly different for patients treated by paramedics as opposed to ambulance technicians. Paramedics spent significantly longer at the scene of the arrest than technicians (P < 0.0001).

CONCLUSIONS

The response of ambulance paramedics to patients with cardiopulmonary arrest outside hospital does not provide improved outcome when compared with ambulance technicians using basic techniques and equipped with semi-automatic defibrillators.

Respiratory arrest outside hospital

Of 954 attempted resuscitations outside hospital performed by ambulance personnel, 48 patients (5%) had primary respiratory arrest. Comparing this group with those manifesting cardiorespiratory arrest, patients with primary respiratory arrest were significantly more likely to be female (25 of 48 vs 269 of 906-P < 0.005), were more likely to have a non-cardiac cause (67% vs. 22%-P < 0.00001) and more likely to have witnessed arrest. Of all arrests witnessed by ambulance crew, 35% were respiratory arrests. Basic and advanced life-support was delivered sooner. Outcome was significantly better, with 19 patients (40%) being discharged compared to only 49 patients (5.1%) discharged in cases of cardiorespiratory arrest (p < 0.00001). Considering that many respiratory arrests were witnessed by ambulance crew, the type of crew (EMT or paramedic) made no difference to outcome. Our findings suggest that patients manifesting respiratory arrest outside hospital are a heterogeneous group who have a relatively good prognosis regardless of the type of ambulance crew that attends.

CPR and the single rescuer: at what age should you "call first" rather than "call fast"?

STUDY OBJECTIVE

To determine whether the age-related frequency of ventricular fibrillation (VF) in cardiac arrest supports the guideline that single rescuers should "call first" for all victims of sudden collapse older than 8 years.

DESIGN

Analysis of data on all nontraumatic cardiac arrests treated by emergency medical service (EMS) personnel in King County, Washington, between 1976 and 1992.

MEASUREMENTS

Age, initial cardiac rhythm, witnessed versus unwitnessed status, whether patient was discharged alive.

RESULTS

We analyzed 10,992 cardiac arrests. Initial rhythm was VF in 4,252 (40%) and non-VF in 6,740 (60%). VF frequencies were 3% (0 to 8 years old), 17% (8 to 30 years), and 42% (30 years or older).

CONCLUSION

Most patients under age 30 were not in VF at the time of EMS evaluation. Our data suggest that a "call fast" strategy may be more effective when a single rescuer is present and the victim is between 8 and 30 years old.

Out-of-hospital ventricular fibrillation in children and adolescents: causes and outcomes

STUDY OBJECTIVE

To compare causes and outcomes of patients younger than 20 years with an initial rhythm of ventricular fibrillation versus asystole and pulseless electrical activity.

DESIGN

Retrospective cohort study.

SETTING

Urban/suburban prehospital system.

PARTICIPANTS

Pulseless, nonbreathing patients less than 20 years who underwent out-of-hospital resuscitation. Patients with lividity or rigor mortis or who were less than 6 months old and died of sudden infant death syndrome were excluded.

RESULTS

Ventricular fibrillation was the initial rhythm in 19% (29 of 157) of the cardiac arrests. Rhythm assessment was performed by the first responder in only 44% (69 of 157) of patients. All three rhythm groups were similar in age distribution, frequency of intubation (96%), and vascular access (92%); 93% of ventricular fibrillation patients were defibrillated. The causes of ventricular fibrillation were distributed evenly among medical illnesses, overdoses, drownings, and trauma, only two patients had congenital heart defects. Seventeen percent were discharged with no or mild disability, compared with 2% of asystole/pulseless electrical activity patients (P = .003).

CONCLUSION

Ventricular fibrillation is not rare in child and adolescent prehospital cardiac arrest, and these patients have a better outcome than those with asystole or pulseless electrical activity. Earlier recognition and treatment of ventricular fibrillation might improve pediatric cardiac arrest survival rates.

Can correct closed-chest compressions be performed during prehospital transport?

INTRODUCTION

The resuscitation rate from out-of-hospital cardiac arrest is low. There are many factors to be considered as contributing to this phenomenon. One factor not previously considered is the impact of a moving ambulance environment on the ability to perform closed-chest compressions.

HYPOTHESIS

Proper closed-chest compressions can be performed in a moving ambulance.

METHODS

A cardiopulmonary resuscitation (CPR) training mannequin with an attached skill meter (Skillmeter ResusciAnnie, Laerdal, Armonk, N.Y., USA) that measures each chest compression for proper depth and hand placement was used. Ten emergency medical technician-basic (EMT-B) certified prehospital providers were assigned into one of five teams. Each team performed a total of four sessions of five minutes of continuous closed-chest compressions on the mannequin. Two sessions were done by each team: one in the control environment with the mannequin placed on the floor, and the other in the experimental environment with the mannequin placed in the back of a moving ambulance. The ambulance was operated without warning lights and siren, and all traffic rules were obeyed. The percentage of correct closed-chest compressions was recorded for each session, and the mean values were compared using Student's t-test with alpha set at 0.01 for statistical significance.

RESULTS

Ten sessions of compressions were done in both environments. The mean percentage of correct compressions was 77.6 +/- 15.6 for the control group and 45.6 +/- 18.3 for the ambulance group (p = 0.0005).

CONCLUSION

A moving ambulance environment appears to impair the ability to perform closed-chest compressions.

Out-of-hospital cardiac arrest: two and a half years experience of an accident and emergency department in Hong Kong

The results are presented of 2 1/2 years of experience of patients with out-of-hospital cardiac arrests who were resuscitated in an accident and emergency department (A&E) attached to an acute district hospital in Hong Kong. Out of 263 cases of out-of-hospital cardiac arrest as a result of a variety of causes only seven patients survived (3%) and among the 135 patients with cardiac aetiology only four survived (3%). Ways to improve the outcome for out-of-hospital cardiac arrest are discussed.

Evaluation of outcome following cardiac arrest in patients presenting to two Scottish emergency departments

OBJECTIVES

To compare and contrast outcomes following cardiac arrest managed in two Accident and Emergency departments, and to identify factors which might account for such differences.

DESIGN

Prospective 1-year evaluation of patients sustaining an out-of-hospital cardiac arrest.

SETTING

The Accident and Emergency departments of the Edinburgh (ERI) and Glasgow (GRI) Royal Infirmaries which serve two large urban municipalities.

PATIENTS

All patients sustaining a prehospital cardiac arrest and brought to ERI or GRI were included. Children (< 13 years), those declared dead on arrival at the scene, and events related to poisoning, near drowning, trauma and pregnancy were excluded.

MEASUREMENTS AND MAIN RESULTS

There were 297 prehospital arrests from ERI, and 158 from GRI. Eighty-two (27.6%) were admitted as 'in-patients' to ERI and 23 (14.6%) to GRI (P < 0.01). Thirty-nine (13.1%) survived to hospital discharge from ERI; 13 (8.2%) survived to discharge from GRI (NS). The proportion of VF/VT:Asystole observed was significantly different between the two centres--162:98 from ERI, 54:73 from GRI (P < 0.001). Significantly more prehospital arrests were witnessed and received bystander CPR in those brought to ERI (P < 0.02). For the combined VF/VT/Asystole groups the ERI ambulance response times were significantly shorter (P < 0.01). However, there was no significant difference in the collapse to EMS arrival at the scene times between ERI and GRI. Two survivors from ERI had asystole as their initial observed rhythm. From GRI, one survivor had asystole, one had electromechanical dissociation and in another the initial rhythm was unknown. No survivor to discharge had severe neurological disability.

CONCLUSIONS

Patients suffering out-of-hospital cardiac arrests in Edinburgh have a significantly better chance of being admitted to a ward. There is a trend favouring better survival to discharge in Edinburgh, but with the numbers investigated this does not achieve statistical significance. Amongst those factors which contribute to survival there are fewer witnessed arrests, less bystander CPR and slower ambulance response times in those brought to GRI. There is a need to investigate the environment in which patients collapse, to train the public in CPR, and to review the efficiency and resourcing of the ambulance service.

Failure of ambulance crew to initiate cardiopulmonary resuscitation

The Utstein style of reporting out-of-hospital cardiac arrests requires that all confirmed cardiac arrests considered for resuscitation are analysed and that a record is made of the number of cases where no resuscitation is attempted. We report a series of 942 confirmed cardiac arrests considered for resuscitation by South Glamorgan Emergency Medical Service (EMS). There were 370 (39.3%) cases where no resuscitation was attempted by the EMS. The ages, male/female ratio and EMS response times were similar in both the group that received ambulance resuscitation and those that did not. Those not receiving resuscitation were less likely to have had an arrest of cardiac aetiology (51.3% vs. 75%, P < 0.00001). Rigor mortis or decomposition of the body was present in 50.8% of cases and in 20% a doctor had already confirmed the patient dead. In the remainder the ambulance crew failed to start resuscitation for a variety of reasons.

Pre-hospital cardiac arrest: room for improvement

OBJECTIVE

To audit the outcome from pre-hospital cardiac arrest managed by ambulance personnel, and to assess their proficiency by analysing the time to initiate basic and advanced cardiac life support, the compliance with national guidelines, and the overall success of resuscitation.

DESIGN

A retrospective analysis of ambulance service report forms of pre-hospital cardiac arrests, where active resuscitation was attempted by ambulance personnel between October 1992 and May 1993.

SETTING

The City of Salford.

SUBJECTS

100 consecutive patients who suffered cardiac arrest out-of-hospital and who were brought to the accident and emergency department of Hope Hospital alive, or with resuscitation still in progress.

RESULTS

Only 4 of 100 patients were successfully resuscitated out of hospital, of whom 2 survived to leave hospital. Detailed analysis of pre-hospital performance was performed on 89 patients only, as 11 report forms were missing (no successful pre-hospital resuscitations in this 11). Ventricular fibrillation was the first recorded rhythm in 51.7%, but 85.7% were in asystole or electromechanical dissociation on arrival at hospital. No patient who was still in cardiac arrest on arrival at hospital was successfully resuscitated. 11 patients received 'bystander CPR'. The median time to basic life support was 6 min; the median call-to-response interval was 8 min; the median call-to-advanced cardiac life support interval was 21 min; the median on-scene time was 31 min (paramedics), or 15 min (technicians). The dose of drugs given by the intravenous route did not comply with the contemporary recommendations in 43.2%, and those doses given by the endotracheal route were inadequate in 37.9% of the cases. Endotracheal intubation was attempted in all paramedic resuscitations (91.4% success); intravenous access was attempted in 60.3% (91.7% success).

CONCLUSIONS

The survival from pre-hospital cardiac arrest in this community is worse than the national average. There is no single explanation for this. Better community CPR training, greater efficiency at the scene through additional personnel, and stricter compliance with national ACLS guidelines, facilitated by extended refresher training, are all required if outcome is to be improved.

Strengthening the in-hospital chain of survival with rapid defibrillation by first responders using automated external defibrillators: training and retention issues

STUDY OBJECTIVE

To determine whether staff outside critical care areas who were proficient in basic life support (BLS) could be easily trained to use automated external defibrillators (AEDs) and whether they would retain these skills.

DESIGN

Prospective, longitudinal cohort series.

SETTING

Two university teaching hospitals.

PARTICIPANTS

One hundred forty nurses who had previously learned BLS and constituted the staff from three medical/surgical nursing units from each study hospital.

INTERVENTIONS

The nurses were taught how to use the Heartstart 1000s, a lightweight portable shock-advisory AED, in a 2-hour class with an instructor and manikin-to-student ratio of 1:5. The course emphasized hands-on practice of the BLS-AED algorithm on a computerized manikin.

RESULTS

Using a similar scenario, each nurse was evaluated on the computerized manikin immediately after training (posttest). At 1 to 3, 4 to 6, and 7 to 9 months after the initial training, convenience samples of the cohort in three different groups were evaluated for retention. Satisfactory performance was defined as delivery of the first AED shock within 2 minutes of recognition of the arrest. At the posttest after training, 139 of 140 nurses (99%) demonstrated satisfactory performance. Of 77 nurses evaluated, 31 of 32 at 1 to 3 months, 18 of 18 at 4 to 6 months, and 24 of 27 at 7 to 9 months after initial training (95% overall) performed satisfactorily.

CONCLUSION

As has been demonstrated with prehospital emergency personnel, nurses outside critical care areas who are proficient in BLS can easily learn and retain the knowledge and skills to use AEDs. Automated external defibrillation, a BLS skill, should be incorporated into BLS programs (BLS-AED) for all hospital personnel expected to respond to a patient in cardiac arrest, with rapid defibrillation taking priority over CPR.