The reluctance of house staff to perform mouth-to-mouth resuscitation in the inpatient setting: what are the considerations?

Five vs. two initial rescue breaths during infant basic life support: A manikin study using bag-mask-ventilation

BACKGROUND AND OBJECTIVES

Children are more likely to suffer a hypoxic-ischaemic cause for cardiac arrest. Early ventilation may provide an advantage in outcome during paediatric cardiopulmonary resuscitation [CPR]. European Resuscitation Council guidelines recommend five initial rescue breaths [IRB] in infants, stemming from the hypothesis that rescuers might need 5 attempts in order to deliver 2 effective ventilations. This study aimed to verify this hypothesis.

METHODS

Participants (n = 112, convenience sample) were medical students from the Faculty of Medicine and Health Sciences Ghent University, Belgium. Students were divided into duos and received a 15 min just-in-time training regarding the full CPR-cycle using BMV. Participants then performed five cycles of 2-person CPR. The IRB were given by 1-person BMV, as opposed to a 2-persons technique during the further CPR-cycle. Correct ventilations for the infant were defined as tidal volumes measured (Laerdal® Q-CPR) between 20 and 60 ml, with n = 94 participants included in the analysis. The primary outcome consisted of the difference in the % of medical student duos providing at least 2 effective IRB between 2 and 5 attempts.

RESULTS

Off all duos, 55,3% provided correct volumes during their first 2 initial ventilations. An increase up to 72,4% was noticed when allowing 5 ventilations. The proportional difference between 2 and 5 IRB allowed was thus significant [17,0%, 95% confidence interval (5.4; 28.0)].

CONCLUSION

In this manikin study, 5 IRB attempts during infant CPR with BMV increased the success rate in delivering 2 effective ventilations. Besides, students received training emphasizing the need for 5 initial rescue breaths. This study provides evidence supporting European Resuscitation Council guidelines.

Public attitudes towards cardiopulmonary resuscitation training and performance in Singapore

Background

Bystander cardiopulmonary resuscitation (CPR) rates remain fairly low through most communities despite multiple interventions through the years. Understanding the attitudes and fears behind CPR training and performance would help target education and training to raise the rates of bystander CPR and consequently survival rates of victims. 7909 participants at a single-day mass CPR training session in Singapore were given survey questionnaires to fill out. 6473 people submitted completed forms upon the conclusion of the training session. Some issues looked at were the overall level of difficulty of CPR, difficulty levels of specific skills, attitudes towards refresher training, attitudes towards performing CPR, and fears when doing so.

Results

The mean level of difficulty of CPR was rated 3.98 (scale of 1–10), with those with previous CPR training rating it easier. The skills rated most difficult were performing mouth-to-mouth breathing and chest compressions, while the easiest rated was recognizing non-responsiveness. A majority (69.7%) would agree to go for refresher training every 2 years and 88.7% felt everyone should be trained in CPR. 71.6% would perform full CPR for a member of the public in cardiac arrest and only 20.7% would prefer to only do chest compressions. The most cited fear was a low level of confidence, and fears of acquiring infections or aversion to mouth-to-mouth breathing were low.

Conclusions

The survey results show that most participants in Singapore are keen to perform conventional CPR for a member of the public and can help to target future CPR training accordingly.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12245-021-00378-1.

Transmission of Infections during Cardiopulmonary Resuscitation

Cardiopulmonary resuscitation (CPR) is an emergency lifesaving endeavor, performed in either the hospital or outpatient settings, that significantly improves outcomes and survival rates when performed in a timely fashion. As with any other medical procedure, CPR can bear potential risks not only for the patient but also for the rescuer. Among those risks, transmission of an infectious agent has been one of the most compelling triggers of reluctance to perform CPR among providers. The concern for transmission of an infection from the resuscitated subject may impede prompt initiation and implementation of CPR, compromising survival rates and neurological outcomes of the patients. Infections during CPR can be potentially acquired through airborne, droplet, contact, or hematogenous transmission. However, only a few cases of infection transmission have been actually reported globally. In this review, we present the available epidemiological findings on transmission of different pathogens during CPR and data on reluctance of health care workers to perform CPR. We also outline the levels of personal protective equipment and other protective measures according to potential infectious hazards that providers are potentially exposed to during CPR and summarize current guidelines on protection of CPR providers from international societies and stakeholders.

Experiences and Psychological Influences in Lay Rescuers Performing Bystander Cardiopulmonary Resuscitation: A Qualitative Study

BACKGROUND

Bystander-initiated cardiopulmonary resuscitation (CPR) and the use of automated external defibrillation (AED) is pivotal in the community chain of survival, but little is known regarding the bystander experience of performing CPR and AED, and their psychological infl uence from the incidents in the Asian community. This qualitative study was conducted to explore the experiences of lay rescuers who had performed CPR and AED in public locations in Taiwan.

METHODS

Lay rescuers who had provided initial CPR and defi brillation with AED in public locations across Taiwan in 2015 were selectively recruited from Taiwan Public AED Registry for a semi-structured interview.

RESULTS

Nine participants were included in the study, and event-to-interview duration was within 1 year (n = 4) and 1-2 years (n = 5). The major fi ndings from the study were: (1) the lay rescuers possessed helping traits and high motivation; (2) the lay rescuers reported certain aspects of rescue reality that differed much from prior training and expectations, including diffi culty in the depth of chest compression, and uncertainties in real emergency situations; (3) the lay rescuers gained positive personal fulfi llment in sharing their experience and receiving positive feedback from others, and were willing to help next time, although they experienced a short-term negative psychological impact from the event.

CONCLUSIONS

This study provides valuable information on strategies to increase layperson CPR rates and effectiveness in CPR training. Measures should be taken to increase layperson's confi dence and situation awareness, reduce training-reality discrepancy, build up a support system to avoid negative psychological effects, and prepare lay rescuers for the next resuscitation.

Telecommunicator Cardiopulmonary Resuscitation: A Policy Statement From the American Heart Association

Every year in the United States, >350 000 people have sudden cardiac arrest outside of a hospital environment. Sudden cardiac arrest is the unexpected loss of heart function, breathing, and consciousness and is commonly the result of an electric disturbance in the heart. Unfortunately, only ≈1 in 10 victims survives this dramatic event. Early access to 9-1-1 and early cardiopulmonary resuscitation (CPR) are the first 2 links in the chain of survival for out-of-hospital cardiac arrest. Although 9-1-1 is frequently accessed, in the majority of cases, individuals with out-of-hospital cardiac arrest do not receive lay rescuer CPR and wait for the arrival of professional emergency rescuers. Telecommunicators are the true first responders and a critical link in the cardiac arrest chain of survival. In partnership with the 9-1-1 caller, telecommunicators have the first opportunity to identify a patient in cardiac arrest and provide initial care by delivering CPR instructions while quickly dispatching emergency medical services. The telecommunicator and the caller form a unique team in which the expertise of the telecommunicator is provided just in time to a willing caller, transforming the caller into a lay rescuer delivering CPR. The telecommunicator CPR (T-CPR) process, also previously described as dispatch CPR, dispatch-assisted CPR, or telephone CPR, represents an important opportunity to improve survival from sudden cardiac arrest. Conversely, failure to provide T-CPR in this manner results in preventable harm. This statement describes the public health impact of out-of-hospital cardiac arrest, provides guidance and resources to construct and maintain a T-CPR program, outlines the minimal acceptable standards for timely and high-quality delivery of T-CPR instructions, and identifies strategies to overcome common implementation barriers to T-CPR.

Cardiocerebral and cardiopulmonary resuscitation - 2017 update

Sudden cardiac arrest is a major public health problem in the industrialized nations of the world. Yet, in spite of recurrent updates of the guidelines for cardiopulmonary resuscitation and emergency cardiac care, many areas have suboptimal survival rates. Cardiocerebral resuscitation, a non‐guidelines approach to therapy of primary cardiac arrest based on our animal research, was instituted in Tucson (AZ, USA) in 2002 and subsequently adopted in other areas of the USA. Survival rates of patients with primary cardiac arrest and a shockable rhythm significantly improved wherever it was adopted. Cardiocerebral resuscitation has three components: the community, the pre‐hospital, and the hospital. The community component emphasizes bystander recognition and chest compression only resuscitation. Its pre‐hospital or emergency medical services component emphasizes: (i) urgent initiation of 200 uninterrupted chest compressions before and after each indicated single defibrillation shock, (ii) delayed endotracheal intubation in favor of passive delivery of oxygen by a non‐rebreather mask, (iii) early adrenaline administration. The hospital component was added later. The national and international guidelines for cardiopulmonary resuscitation and emergency medical services are still not optimal, for several reasons, including the fact that they continue to recommend the same approach for two entirely different etiologies of cardiac arrest: primary cardiac arrest, often caused by ventricular fibrillation, where the arterial blood oxygenation is little changed at the time of the arrest, and secondary cardiac arrest from severe respiratory insufficiency, where the arterial blood is severely desaturated at the time of cardiac arrest. These different etiologies need different approaches to therapy.

Continuous chest compression versus interrupted chest compression for cardiopulmonary resuscitation of non-asphyxial out-of-hospital cardiac arrest

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a major cause of death worldwide. Cardiac arrest can be subdivided into asphyxial and non asphyxial etiologies. An asphyxia arrest is caused by lack of oxygen in the blood and occurs in drowning and choking victims and in other circumstances. A non asphyxial arrest is usually a loss of functioning cardiac electrical activity. Cardiopulmonary resuscitation (CPR) is a well-established treatment for cardiac arrest. Conventional CPR includes both chest compressions and 'rescue breathing' such as mouth-to-mouth breathing. Rescue breathing is delivered between chest compressions using a fixed ratio, such as two breaths to 30 compressions or can be delivered asynchronously without interrupting chest compression. Studies show that applying continuous chest compressions is critical for survival and interrupting them for rescue breathing might increase risk of death. Continuous chest compression CPR may be performed with or without rescue breathing.

OBJECTIVES

To assess the effects of continuous chest compression CPR (with or without rescue breathing) versus conventional CPR plus rescue breathing (interrupted chest compression with pauses for breaths) of non-asphyxial OHCA.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 1 2017); MEDLINE (Ovid) (from 1985 to February 2017); Embase (1985 to February 2017); Web of Science (1985 to February 2017). We searched ongoing trials databases including controlledtrials.com and clinicaltrials.gov. We did not impose any language or publication restrictions.

SELECTION CRITERIA

We included randomized and quasi-randomized studies in adults and children suffering non-asphyxial OHCA due to any cause. Studies compared the effects of continuous chest compression CPR (with or without rescue breathing) with interrupted CPR plus rescue breathing provided by rescuers (bystanders or professional CPR providers).

DATA COLLECTION AND ANALYSIS

Two authors extracted the data and summarized the effects as risk ratios (RRs), adjusted risk differences (ARDs) or mean differences (MDs). We assessed the quality of evidence using GRADE.

MAIN RESULTS

We included three randomized controlled trials (RCTs) and one cluster-RCT (with a total of 26,742 participants analysed). We identified one ongoing study. While predominantly adult patients, one study included children. Untrained bystander-administered CPRThree studies assessed CPR provided by untrained bystanders in urban areas of the USA, Sweden and the UK. Bystanders administered CPR under telephone instruction from emergency services. There was an unclear risk of selection bias in two trials and low risk of detection, attrition, and reporting bias in all three trials. Survival outcomes were unlikely to be affected by the unblinded design of the studies.We found high-quality evidence that continuous chest compression CPR without rescue breathing improved participants' survival to hospital discharge compared with interrupted chest compression with pauses for rescue breathing (ratio 15:2) by 2.4% (14% versus 11.6%; RR 1.21, 95% confidence interval (CI) 1.01 to 1.46; 3 studies, 3031 participants).One trial reported survival to hospital admission, but the number of participants was too low to be certain about the effects of the different treatment strategies on survival to admission(RR 1.18, 95% CI 0.94 to 1.48; 1 study, 520 participants; moderate-quality evidence).There were no data available for survival at one year, quality of life, return of spontaneous circulation or adverse effects.There was insufficient evidence to determine the effect of the different strategies on neurological outcomes at hospital discharge (RR 1.25, 95% CI 0.94 to 1.66; 1 study, 1286 participants; moderate-quality evidence). The proportion of participants categorized as having good or moderate cerebral performance was 11% following treatment with interrupted chest compression plus rescue breathing compared with 10% to 18% for those treated with continuous chest compression CPR without rescue breathing. CPR administered by a trained professional In one trial that assessed OHCA CPR administered by emergency medical service professionals (EMS) 23,711 participants received either continuous chest compression CPR (100/minute) with asynchronous rescue breathing (10/minute) or interrupted chest compression with pauses for rescue breathing (ratio 30:2). The study was at low risk of bias overall.After OHCA, risk of survival to hospital discharge is probably slightly lower for continuous chest compression CPR with asynchronous rescue breathing compared with interrupted chest compression plus rescue breathing (9.0% versus 9.7%) with an adjusted risk difference (ARD) of -0.7%; 95% CI (-1.5% to 0.1%); moderate-quality evidence.There is high-quality evidence that survival to hospital admission is 1.3% lower with continuous chest compression CPR with asynchronous rescue breathing compared with interrupted chest compression plus rescue breathing (24.6% versus 25.9%; ARD -1.3% 95% CI (-2.4% to -0.2%)).Survival at one year and quality of life were not reported.Return of spontaneous circulation is likely to be slightly lower in people treated with continuous chest compression CPR plus asynchronous rescue breathing (24.2% versus 25.3%; -1.1% (95% CI -2.4 to 0.1)), high-quality evidence.There is high-quality evidence of little or no difference in neurological outcome at discharge between these two interventions (7.0% versus 7.7%; ARD -0.6% (95% CI -1.4 to 0.1).Rates of adverse events were 54.4% in those treated with continuous chest compressions plus asynchronous rescue breathing versus 55.4% in people treated with interrupted chest compression plus rescue breathing compared with the ARD being -1% (-2.3 to 0.4), moderate-quality evidence).

AUTHORS' CONCLUSIONS

Following OHCA, we have found that bystander-administered chest compression-only CPR, supported by telephone instruction, increases the proportion of people who survive to hospital discharge compared with conventional interrupted chest compression CPR plus rescue breathing. Some uncertainty remains about how well neurological function is preserved in this population and there is no information available regarding adverse effects.When CPR was performed by EMS providers, continuous chest compressions plus asynchronous rescue breathing did not result in higher rates for survival to hospital discharge compared to interrupted chest compression plus rescue breathing. The results indicate slightly lower rates of survival to admission or discharge, favourable neurological outcome and return of spontaneous circulation observed following continuous chest compression. Adverse effects are probably slightly lower with continuous chest compression.Increased availability of automated external defibrillators (AEDs), and AED use in CPR need to be examined, and also whether continuous chest compression CPR is appropriate for paediatric cardiac arrest.

Advancing resuscitation science

PURPOSE OF REVIEW

To describe an alternative approach for improving survival of patients with out-of-hospital cardiac arrest (OHCA). The survival of patients with OHCA has been poor and relatively unchanged for decades in spite of recurrent national and international guidelines. Although there are exceptions, many thought and continue to think that any change in the guidelines for cardiopulmonary resuscitation should be based on randomized controlled trials in humans. However, many factors, including the need for informed consent, the marked variability of patients, and the variability of the type and quality of bystander and advanced resuscitation efforts, all make such studies problematic. Thus, potentially life-saving procedures are often withheld for decades, resulting in unnecessary loss of life.

RECENT FINDINGS

Many improvements in public health conditions have been made using models of continuous quality improvement. When applied to resuscitation science, once baseline data are obtained, changes based on reliable experimental findings are instituted and outcomes measured. This approach has now been shown to result in significant improvement in neurologically intact survival of patients with OHCA.

SUMMARY

Following this model, we found significant improvement in survival of patients with a witnessed OHCA primary cardiac arrest.

Dispatch-assisted cardiopulmonary resuscitation: the anchor link in the chain of survival

PURPOSE OF REVIEW

Early bystander cardiopulmonary resuscitation (CPR) provides a vital bridge after collapse from cardiac arrest until defibrillation can be performed. However, due to multiple barriers and despite large-scale public CPR training, this life-saving therapy is still not rendered in a majority of cardiac arrest events. As a result, cardiac arrest survival remains very low in most communities.

RECENT FINDINGS

Several large-scale studies have shown the benefits of dispatch-assisted CPR. These studies have confirmed that on-going dispatch-assisted CPR programs that use a simplified and abbreviated set of standardized questions can hasten the recognition of cardiac arrest. Dispatchers can also utilize strategies to help bystanders overcome the obstacles to beginning CPR. In some communities, dispatch-assisted CPR accounts for up to half of all bystander CPR. Dispatch-assisted CPR programs combined with large-scale public CPR training may be what is needed to elevate CPR rates and survival from out-of-hospital cardiac arrest nationally.

SUMMARY

This review focuses on the rationale and evolving science behind dispatch CPR instructions, as well as some best practices for implementing and measuring dispatch-assisted CPR with the goal of maximizing its potential to save lives from sudden cardiac arrest.

Ethical and practical considerations in providing critical care to patients with Ebola virus disease

Infectious disease epidemics in the past have given rise to psychologic and emotional responses among health-care workers (HCWs), stemming from fear of infection during patient care. Early experiences in the AIDS epidemic provide an example where fear of contagion resulted in differential treatment of patients infected with HIV. However, with a deeper understanding of AIDS pathogenesis and treatment, fear and discrimination diminished. Parallels exist between early experiences with AIDS and the present outbreak of Ebola virus disease in West Africa, particularly regarding discussions of medical futility in seriously ill patients. We provide a historical perspective on HCWs' risk of infection during the provision of CPR, discuss physicians' duty to treat in the face of perceived or actual HCW risk, and, finally, present the protocols implemented at the National Institutes of Health to reduce HCW risk while providing lifesaving and life-sustaining care.

Cardiopulmonary resuscitation, chest compression only and teamwork from the perspective of medical doctors, surgeons and anesthesiologists

Background:

New resuscitation guidelines that were proposed by the European Resuscitation Council in 2010 have introduced a new method of cardiopulmonary resuscitation (CPR) by chest compressions only for untrained individuals.

Objectives:

We conducted this study to evaluate differences in attitudes towards CPR among medical doctors, surgeons and anesthesiologists in Osijek University Hospital. A call for help, chest-compression-only resuscitation, mouth-to-mouth ventilation and team-work were recognized as critical points that may influence the outcome. Unfamiliarity with these methods may be indicative of a lack of education in resuscitation and may result in poor outcomes for victims.

Patients and Methods:

An anonymous survey was conducted on 190 medical professionals: 93 medical doctors, 70 surgeons, and 27 anesthesiologists during year 2012 (mean age 41.9 years). The questions were related to previous education in resuscitation, current resuscitation practices and attitudes towards cardiopulmonary resuscitation. Data were analyzed using ANOVA and Fisher exact test. A P value of < 0.05 was considered statistically significant.

Results:

The only difference between groups was regarding the male and female ratio, with more male surgeons (45, 55, and 11, P < 0.001). All doctors considered CPR as important, but only anesthesiologists knew how often guidelines in CPR change. Approximately 45% of medical doctors, 48% of surgeons and 77% of anesthesiologists reported that they have renewed their knowledge in CPR within the last five years, whereas 34%, 25% and 22% had never renewed their knowledge in the CPR (P = 0.01 between surgeons anesthesiologists). Furthermore, chest-compression-only was recognized as a valuable CPR technique by 25.8% of medical doctors, 14.3% of surgeons and 59.3% of anesthesiologists (P < 0.001). Anesthesiologists estimated a high risk of infection transmission (62%) and were more likely to refuse mouth-to-mouth ventilation when compared to surgeons (25% vs.10%, P = 0.01). Anesthesiologists are most often called for help by their colleagues, only rarely surgeons call their departmental colleagues and nurses to help in CPR.

Conclusions:

An insufficient formal education in CPR was registered for all groups, reflecting the lack of familiarity with new CPR methods. A team education, involving doctors and nurses may improve familiarity with CPR and patient outcomes.

Understanding and improving low bystander CPR rates: a systematic review of the literature

Objectives:

Cardiopulmonary resuscitation (CPR) is a crucial yet weak link in the chain of survival for out-of-hospital cardiac arrest. We sought to understand the determinants of bystander CPR and the factors associated with successful training.

Methods:

For this systematic review, we searched 11 electronic databases, 1 trial registry and 9 scientific websites. We performed hand searches and contacted 6 content experts. We reviewed without restriction all communications pertaining to who should learn CPR, what should be taught, when to repeat training, where to give CPR instructions and why people lack the motivation to learn and perform CPR. We used standardized forms to review papers for inclusion, quality and data extraction. We grouped publications by category and classified recommendations using a standardized classification system that was based on level of evidence.

Results:

We reviewed 2409 articles and selected 411 for complete evaluation. We included 252 of the 411 papers in this systematic review. Differences in their study design precluded a meta-analysis. We classified 22 recommendations; those with the highest scores were 1) 9-1-1 dispatch-assisted CPR instructions, 2) teaching CPR to family members of cardiac patients, 3) Braslow's self-training video, 4) maximizing time spent using manikins and 5) teaching the concepts of ambiguity and diffusion of responsibility. Recommendations not supported by evidence include mass training events, pulse taking prior to CPR by laymen and CPR using chest compressions alone.

Conclusion:

We evaluated and classified the potential impact of interventions that have been proposed to improve bystander CPR rates. Our results may help communities design interventions to improve their bystander CPR rates.

Over-the-head two-thumb encircling technique as an alternative to the two-finger technique in the in-hospital infant cardiac arrest setting: a randomised crossover simulation study

OBJECTIVE

To determine if the over-the-head two-thumb encircling technique (OTTT) provides better quality cardiopulmonary resuscitation (CPR) than the conventional two-finger technique (TFT) when performed by a lone rescuer in an in-hospital infant cardiac arrest setting.

METHODS

This prospective, randomised crossover design study recruited 50 nurses who voluntarily performed lone rescuer infant CPR for 2 min on a manikin. Participants who performed OTTT stood at the head of the manikin to compress the chest and provide bag-valve mask ventilations, whereas those who performed TFT stood by the side of the manikin to compress the chest and provide pocket-mask ventilations. Mean hands-off time, mean compression depths and rates, proportion of effective compressions and complete recoil, and fatigue score changes were assessed during the test, and a survey on the ease of use of the techniques was conducted after the test.

RESULTS

Hands-off time, total ventilation volume and number of ventilations were not significantly different between the two techniques. OTTT resulted in greater depth of compressions (p<0.001), greater proportion of effective compressions (p<0.001), smaller proportion of complete recoil (p=0.001), and smaller fatigue score change (p=0.003) than TFT. In addition, subjects reported that compression, ventilation and changing compression to ventilation were easier using OTTT than TFT.

CONCLUSIONS

OTTT performed by a lone rescuer in an in-hospital infant cardiac arrest setting resulted in greater compression depth, with no increase in hands-off time, compared with TFT. OTTT may therefore be a suitable alternative to TFT in the in-hospital infant cardiac arrest setting.

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

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

Out-of-hospital cardiac arrest: 10 years of progress in research and treatment

Cardiac disease is the most common cause of mortality in Western countries, with most deaths due to out-of-hospital cardiac arrest (OHCA). In Sweden, 5000-10 000 OHCAs occur annually. During the last decade, the time from cardiac arrest to start of cardiopulmonary resuscitation (CPR) and defibrillation has increased, whereas survival has remained unchanged or even increased. Resuscitation of OHCA patients is based on the 'chain-of-survival' concept, including early (i) access, (ii) CPR, (iii) defibrillation, (iv) advanced cardiac life support and (v) post-resuscitation care. Regarding early access, agonal breathing, telephone-guided CPR and the use of 'track and trigger systems' to detect deterioration in patients' condition prior to an arrest are all important. The use of compression-only CPR by bystanders as an alternative to standard CPR in OHCA has been debated. Based on recent findings, guidelines recommend telephone-guided chest compression-only CPR for untrained rescuers, but trained personnel are still advised to give standard CPR with both compressions and ventilation, and the method of choice for this large group remains unclear and demands for a randomized study. Data have shown the benefit of public access defibrillation for dispatched rescuers (e.g. police and fire fighters) but data are not as strong for the use of automated defibrillators (AEDs) by trained or untrained rescuers. Postresuscitation, use of therapeutic hypothermia, the importance of specific prognostic survival factors in the intensive care unit and the widespread use of percutaneous coronary intervention have all been considered. Despite progress in research and improved treatment regimens, most patients do not survive OHCA. Particular areas of interest for improving survival include (i) identification of high-risk patients prior to their arrest (e.g. early warning symptoms and genes); (ii) increased use of bystander CPR training (e.g. in schools) and simplified CPR techniques; (iii) better identification of high-incidence sites and better recruitment of AEDs (via mobile phone solutions?); (iv) improved understanding of the use of therapeutic hypothermia; (v) determining which patients should undergo immediate coronary angiography on hospital admission; and (vi) clarifying the importance of extracorporeal membrane oxygenation during CPR.

Barriers and facilitators to CPR knowledge transfer in an older population most likely to witness cardiac arrest: a theory-informed interview approach

BACKGROUND

We sought to identify perceived barriers and facilitators to cardiopulmonary resuscitation (CPR) training and performing CPR among people above the age of 55 years.

METHODS

We conducted semistructured qualitative interviews with a purposive sample of independent-living individuals aged 55 years and older from urban and rural settings. We developed an interview guide based on the constructs of the Theory of Planned Behaviour, which elicits salient attitudes, social influences and control beliefs potentially influencing CPR training and performance. Interviews were recorded, transcribed verbatim and analysed until achieving data saturation. Two independent reviewers performed inductive analyses to identify emerging themes, and ranked them by way of consensus.

RESULTS

Demographics for the 24 interviewees: mean age 71.4 years, women 58.3%, urban location 75.0%, single dwelling 58.3%, CPR training 79.2% and prior CPR on real victim 8.3%. Facilitators of CPR training included: (1) classes in a convenient location; (2) more advertisements; and (3) having a spouse. Barriers to taking CPR training included: (1) perception of physical limitations; (2) time commitment; and (3) cost. Facilitators of providing CPR included: (1) 9-1-1 CPR instructions; (2) reminders/pocket cards; and (3) frequent but brief updates. Barriers to providing CPR included: (1) physical limitations; (2) lack of confidence; and (3) ambivalence of duty to act in a large group.

CONCLUSIONS

We identified key facilitators and barriers for CPR training and performance in a purposive sample of individuals aged 55 years and older.

Cardiopulmonary resuscitation in real life: the most frequent fears of lay rescuers

INTRODUCTION

Surviving cardiac arrest depends on early cardiopulmonary resuscitation (CPR). Only one third of cardiac arrest victims receive prompt CPR in spite of well-attended Basic Life Support (BLS) courses. Our study aimed to investigate that how many lay rescuers, capable of performing CPR, would do so, and to analyse their impeding fears.

MATERIALS AND METHODS

After each BLS course for lay rescuers (American Heart Association (AHA) CPR for family and friends), an anonymous questionnaire was distributed asking participants whether they would perform CPR on an adult or on a child in a real case of cardiac arrest. In the case of a negative response, we questioned them why.

RESULTS

A total of 1000 questionnaires were analysed. The sample group was predominantly made up of males (77.7%), Italians (82.2%), individuals aged between 26 and 35 years (41.2%) and individuals possessing a high-school diploma (61.8%). The percentages that would perform CPR on an unknown adult or child were different (86.2% vs. 73.9% p = 0.005). The prevalent fears were regarding infection, being incapable, legal implications and causing damage and fear in general. The first three differ significantly in adult and paediatric cases. Subdividing the population according to sex, age and education did not demonstrate significant differences regarding willingness to perform adult or paediatric CPR.

CONCLUSIONS

This descriptive study demonstrates that the percentage that would really perform CPR is too low, particularly in the case of a child. Part of the course should be dedicated to discussing these arguments to ensure that all those capable of performing good CPR would immediately do so.

Knowledge and attitudes towards cardiopulmonary resuscitation and defibrillation amongst Asian primary health care physicians

Objective

To assess the knowledge and attitudes of local primary health care physicians in relation to cardiopulmonary resuscitation (CPR) and defibrillation.

Methods

We conducted a survey on general practitioners in Singapore by using a self-administered questionnaire that comprised 29 questions.

Results

The response rate was 80%, with 60 of 75 physicians completing the questionnaire. The average age of the respondents was 52 years. Sixty percent of them reported that they knew how to operate an automated external defibrillator (AED), and 38% had attended AED training. Only 36% were willing to perform mouth-to-mouth ventilation during CPR, and 53% preferred chest compression-only resuscitation (CCR) to standard CPR. We found those aged <50 years were more likely to be trained in basic cardiac life support (BCLS) (P < 0.001) and advanced cardiac life support (P = 0.005) or to have ever attended to a patient with cardiac arrest (P = 0.007). Female physicians tended to agree that all clinics should have AEDs (P = 0.005) and support legislation to make AEDs compulsory in clinics (P < 0.001). We also found that a large proportion of physicians who were trained in BCLS (P = 0.006) were willing to perform mouth-to-mouth ventilation.

Conclusion

Most local primary care physicians realize the importance of defibrillation, and the majority prefer CCR to standard CPR.

The willingness of final year medical and dental students to perform bystander cardiopulmonary resuscitation in an Asian community

BACKGROUND

Despite the importance of early effective chest compressions to improve the chance of survival of an out-of-hospital cardiac arrest victim, it is still largely unknown how willing our Malaysian population is to perform bystander cardiopulmonary resuscitation (CPR).

AIMS

We conducted a voluntary, anonymous self-administered questionnaire survey of a group of 164 final year medical students and 60 final year dental students to unravel their attitudes towards performing bystander CPR.

METHODS

Using a 4-point Likert scale of "definitely yes," "probably yes," "probably no," and "definitely no," the students were asked to rate their willingness to perform bystander CPR under three categories: chest compressions with mouth-to-mouth ventilation (CC + MMV), chest compressions with mask-to-mouth ventilation (CC + PMV), and chest compressions only (CC). Under each category, the students were given ten hypothetical victim scenarios. Categorical data analysis was done using the McNemar test, chi-square test, and Fisher exact test where appropriate. For selected analysis, "definitely yes" and "probably yes" were recoded as a "positive response."

RESULTS

Generally, we found that only 51.4% of the medical and 45.5% of the dental students are willing to perform bystander CPR. When analyzed under different hypothetical scenarios, we found that, except for the scenario where the victim is their own family member, all other scenarios showed a dismally low rate of positive responses in the category of CC + MMV, but their willingness was significantly improved under the CC + PMV and CC categories.

CONCLUSION

This study shows that there are unique sociocultural factors that contribute to the reluctance of our students to perform CC + MMV.

A survey of attitudes and factors associated with successful cardiopulmonary resuscitation (CPR) knowledge transfer in an older population most likely to witness cardiac arrest: design and methodology

BACKGROUND

Overall survival rates for out-of-hospital cardiac arrest rarely exceed 5%. While bystander cardiopulmonary resuscitation (CPR) can increase survival for cardiac arrest victims by up to four times, bystander CPR rates remain low in Canada (15%). Most cardiac arrest victims are men in their sixties, they usually collapse in their own home (85%) and the event is witnessed 50% of the time. These statistics would appear to support a strategy of targeted CPR training for an older population that is most likely to witness a cardiac arrest event. However, interest in CPR training appears to decrease with advancing age. Behaviour surrounding CPR training and performance has never been studied using well validated behavioural theories.

METHODS/DESIGN

The overall goal of this study is to conduct a survey to better understand the behavioural factors influencing CPR training and performance in men and women 55 years of age and older. The study will proceed in three phases. In phase one, semi-structured qualitative interviews will be conducted and recorded to identify common categories and themes regarding seeking CPR training and providing CPR to a cardiac arrest victim. The themes identified in the first phase will be used in phase two to develop, pilot-test, and refine a survey instrument based upon the Theory of Planned Behaviour. In the third phase of the project, the final survey will be administered to a sample of the study population over the telephone. Analyses will include measures of sampling bias, reliability of the measures, construct validity, as well as multiple regression analyses to identify constructs and beliefs most salient to seniors' decisions about whether to attend CPR classes or perform CPR on a cardiac arrest victim.

DISCUSSION

The results of this survey will provide valuable insight into factors influencing the interest in CPR training and performance among a targeted group of individuals most susceptible to witnessing a victim in cardiac arrest. The findings can then be applied to the design of trials of various interventions designed to promote attendance at CPR classes and improve CPR performance.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00665288.

Comparison of chest compression only and standard cardiopulmonary resuscitation for out-of-hospital cardiac arrest in Singapore

OBJECTIVE

Chest compression only cardiopulmonary resuscitation (CC-CPR) without ventilation has been proposed as an alternative to standard cardiopulmonary resuscitation (CPR) for bystanders. However, there has been controversy regarding the relative effectiveness of both of these techniques. We aim to compare the outcomes of cardiac arrest patients in the cardiac arrest and resuscitation epidemiology study who either received CC-CPR, standard CPR or no bystander CPR.

METHODS

This prospective cohort study involved all out-of-hospital cardiac arrest (OHCA) patients attended to by emergency medical service (EMS) providers in a large urban centre. The data analyses were conducted secondarily on these collected data. The technique of bystander CPR was reported by paramedics who arrived at the scene.

RESULTS

From 1 October 2001 to 14 October 2004, 2428 patients were enrolled into the study. Of these, 255 were EMS-witnessed arrests and were excluded. 1695 cases did not receive any bystander CPR, 287 had standard CPR and 154 CC-CPR. Patient characteristics were similar in both the standard and CC-CPR groups except for a higher incidence of residential arrests and previous heart disease sufferers in the CC-CPR group. Patients who received standard CPR (odds ratio (OR) 5.4, 95% confidence interval (CI) 2.1-14.0) or CC-CPR (OR 5.0, 95% CI 1.5-16.4) were more likely to survive to discharge than those who had no bystander CPR. There was no significant difference in survival to discharge between those who received CC-CPR and standard CPR (OR 0.9, 95% CI 0.3-3.1).

CONCLUSION

We found that patients were more likely to survive with any form of bystander CPR than without. This emphasises the importance of chest compressions for OHCA patients, whether with or without ventilation.

Emergency department evaluations of non-percutaneous blood or body fluid exposures during cardiopulmonary resuscitation

INTRODUCTION

The demography of healthcare workers (HCWs) and non-HCWs seeking medical care at emergency departments after a non-percutaneous potential exposure to human immunodeficiency virus (HIV) during cardiopulmonary resuscitation (CPR), the types and body locations of their exposures, the time elapsed from exposure to emergency department presentation, and usage of HIV-post-exposure prophylaxis (PEP) for these exposures are described.

METHODS

A retrospective study of emergency department patients who were exposed to blood or body fluids during CPR in Rhode Island from January 1995-June 2001 was performed. The demography, characteristics of the exposure, and HIV-PEP usage for these patients were compared, and the elapsed time from exposure to evaluation in the emergency department was calculated.

RESULTS

Of the 39 patients exposed to non-percutaneous blood or body fluid during CPR, 22 were healthcare workers (HCWs) and 17 were non-HCWs. Thirty-four patients sustained mucous membrane exposures. Most of the patients (69.2%) were exposed to saliva or sputum (p <0.001), experienced a mouth exposure (71.8%; p <0.0001) and presented to the emergency department within one day of their exposure (84.4%; p <0.0001). Three HCWs and no non-HCWs were offered HIV-PEP for their CPR exposure. Of the three HCWs offered PEP, two actually received it.

CONCLUSIONS

Nearly half of the patients who presented with non-percutaneous exposures acquired during CPR were not HCWs. Most of the exposures were to saliva or sputum and occurred on their mucous membranes. Continuing education programs on maintaining universal precautions to prevent blood or body fluid exposures and appreciating the benign nature of most non-percutaneous exposures possible during CPR are needed.

Survival is similar after standard treatment and chest compression only in out-of-hospital bystander cardiopulmonary resuscitation

BACKGROUND

We sought to compare the 1-month survival rates among patients after out-of-hospital cardiac arrest who had been given bystander cardiopulmonary resuscitation (CPR) in relation to whether they had received standard CPR with chest compression plus mouth-to-mouth ventilation or chest compression only.

METHODS AND RESULTS

All patients with out-of-hospital cardiac arrest who received bystander CPR and who were reported to the Swedish Cardiac Arrest Register between 1990 and 2005 were included. Crew-witnessed cases were excluded. Among 11,275 patients, 73% (n=8209) received standard CPR, and 10% (n=1145) received chest compression only. There was no significant difference in 1-month survival between patients who received standard CPR (1-month survival=7.2%) and those who received chest compression only (1-month survival=6.7%).

CONCLUSIONS

Among patients with out-of-hospital cardiac arrest who received bystander CPR, there was no significant difference in 1-month survival between a standard CPR program with chest compression plus mouth-to-mouth ventilation and a simplified version of CPR with chest compression only.

The Save Hearts in Arizona Registry and Education (SHARE) program: Who is performing CPR and where are they doing it?

BACKGROUND

Bystander cardiopulmonary resuscitation (CPR) decreases mortality from out-of-hospital cardiac arrest significantly. Accordingly, layperson CPR is an integral component in the chain of survival for out-of-hospital cardiac arrest victims. The near statewide incidence and location of layperson CPR is unknown.

OBJECTIVE

To determine true incidence and location of layperson CPR in the State of Arizona.

METHODS

The Save Hearts in Arizona Registry and Education (SHARE) program reviewed EMS first care reports submitted voluntarily by 30 municipal fire departments responsible for approximately 67% of Arizona's population. In addition to standard Utstein style data, information regarding the performance of bystander CPR, the vocation and medical training of the bystander and the location of the arrest were documented.

RESULTS

The total number of out-of-hospital adult arrests of presumed cardiac etiology reported statewide was 1097. Cardiac arrests occurred in private residences in 67%, extended care or medical facilities in 18%, and public locations in 15%. Bystander CPR was performed in 37% of all arrests, 24% of residential arrests, 76% of extended care or medical facility arrests, and 52% of public arrests. Bystander CPR provided an odds ratio of 2.2 for survival [95% CI 1.2-4.1]. Excluding cardiac arrests which occurred in the presence of bystanders with formal CPR training as part of their job description, layperson CPR was performed in 218 of 857 (25%) of cases.

CONCLUSIONS

The near statewide incidence of layperson CPR is extremely low. This low rate of bystander CPR is likely to contribute to the low overall survival rates from cardiac arrest. Public health officials should re-evaluate current models of public education on CPR.

Rescuer fatigue: standard versus continuous chest-compression cardiopulmonary resuscitation

OBJECTIVES

Continuous chest-compression cardiopulmonary resuscitation (CCC-CPR) has been advocated as an alternative to standard CPR (STD-CPR). Studies have shown that CCC-CPR delivers substantially more chest compressions per minute and is easier to remember and perform than STD-CPR. One concern regarding CCC-CPR is that the rescuer may fatigue and be unable to maintain adequate compression rate or depth throughout an average emergency medical services response time. The specific aim of this study was to compare the effects of fatigue on the performance of CCC-CPR and STD-CPR on a manikin model.

METHODS

This was a prospective, randomized crossover study involving 53 medical students performing CCC-CPR and STD-CPR on a manikin model. Students were randomized to their initial CPR group and then performed the other type of CPR after a period of at least two days. Students were evaluated on their performance of 9 minutes of CPR for each method. The primary endpoint was the number of adequate chest compressions (at least 38 mm of compression depth) delivered per minute during each of the 9 minutes. The secondary endpoints were total compressions, compression rate, and the number of breaks taken for rest. The students' performance was evaluated on the basis of Skillreporter Resusci Anne (Laerdal, Wappingers Falls, NY) recordings. Primary and secondary endpoints were analyzed by using the generalized linear mixed model for counting data.

RESULTS

In the first 2 minutes, participants delivered significantly more adequate compressions per minute with CCC-CPR than STD-CPR, (47 vs. 32, p = 0.004 in the 1st minute and 39 vs. 29, p = 0.04 in the 2nd minute). For minutes 3 through 9, the differences in number of adequate compressions between groups were not significant. Evaluating the 9 minutes of CPR as a whole, there were significantly more adequate compressions in CCC-CPR vs. STD-CPR (p = 0.0003). Although the number of adequate compressions per minute declined over time in both groups, the rate of decline was significantly greater in CCC-CPR compared with STD-CPR (p = 0.0003). The mean number of total compressions delivered in the first minute was significantly greater with CCC-CPR than STD-CPR (105 per minute vs. 58 per minute, p < 0.001) and did not change over 9 minutes in either group. There were no differences in compression rates or number of breaks between groups.

CONCLUSIONS

CCC-CPR resulted in more adequate compressions per minute than STD-CPR for the first 2 minutes of CPR. However, the difference diminished after 3 minutes, presumably as a result of greater rescuer fatigue with CCC-CPR. Overall, CCC-CPR resulted in more total compressions per minute than STD-CPR during the entire 9 minutes of resuscitation.

Single rescuer cardiopulmonary resuscitation: Can anyone perform to the guidelines 2000 recommendations?

BACKGROUND

The Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care recommend that for adult cardiac arrest the single rescuer performs "two quick breaths followed by 15 chest compressions." This cycle is continued until additional help arrives. Previous studies have shown that lay persons and medical students take 16 +/- 1 and 14 +/- 1 s, respectively, to perform these "two quick breaths." The purpose of this study was to determine the time required for trained professional paramedic firefighters to deliver these two breaths and the effects that any increase in the time it takes to perform rescue breathing would have on the number of chest compressions delivered during single rescuer BLS CPR. We hypothesized that trained professional rescuers would also take substantially longer then the Guidelines recommendation for delivering the two rescue breaths before every 15 compressions during simulated single rescuer BLS CPR.

METHODS

Twenty-four paramedic firefighters currently certified to perform BLS CPR were evaluated for their ability to deliver the two recommended breaths within 4 s according to the AHA 2000 CPR Guidelines. Alternatively, a simplified technique of continuous chest compression BLS CPR (CCC) was also taught and compared with standard BLS CPR (STD). Without revealing the purpose of the study the paramedics were asked to perform single rescuer BLS CPR on a recording Resusci Anne while being videotaped.

RESULTS

The mean length of time needed to provide the "two quick breaths" during STD-CPR was 10 +/- 1 s. The mean number of chest compressions/min delivered with AHA BLS CPR was only 44 +/- 2. Continuous chest compression CPR resulted in 88 +/- 5 compressions delivered per minute (STD versus CCC; p < 0.0001).

CONCLUSIONS

Trained professional emergency rescue workers perform rescue breathing somewhat faster than lay rescuers or medical students, but still require two and one half times longer than recommended. The time required to perform these breaths significantly decreases the number of chest compressions delivered per minute. This may affect outcome as experimental studies have shown that more than 80 compressions delivered per minute are necessary for survival from prolonged cardiac arrest.

Over-the-head cardiopulmonary resuscitation improves efficacy in basic life support performed by professional medical personnel with a single rescuer: a simulation study

Two-rescuer cardiopulmonary resuscitation (CPR) is considered the best method for professional basic life support (BLS). However, in many prehospital cardiac arrest situations, one rescuer has to begin CPR alone while the other performs additional tasks. In theory, over-the-head CPR is a suitable alternative in this situation, with the added benefit of allowing the single rescuer to use a self-inflating bag for ventilation. In this trial, we compared standard single-rescuer CPR with over-the-head CPR in manikins. We planned this study using a crossover study design where each participant administered both CPR techniques in a randomized order. Ventilation and chest compression data were collected with analysis software during a 2-min CPR test for each technique. Sixty-seven emergency medical technician students participated in this trial. Over-the-head CPR allowed for superior ventilation compared to standard CPR (number of correct ventilations: 330 of 760 versus 279 of 779; P = 0.002). The quality of delivered chest compressions did not differ between the two groups (correct chest compressions: 4293 of 6304 versus 4313 of 6395; P = 0.44). In conclusion, our study has shown that over-the-head CPR may be an effective alternative BLS technique when a single professional rescuer has to perform CPR, likely offering superior ventilation and comparable chest compression quality compared with standard BLS.

Uninterrupted chest compression CPR is easier to perform and remember than standard CPR

INTRODUCTION

It has long been observed that CPR skills rapidly decline regardless of the modality used for teaching or criteria used for testing. Uninterrupted chest compression CPR (UCC-CPR) is a proposed alternative to standard single rescuer CPR (STD-CPR) for laypersons in witnessed unexpected cardiac arrest in adults. It delivers substantially more compressions per minute and may be easier to remember and perform than standard CPR.

METHODS

In this prospective study, 28 medical students were taught STD-CPR and UCC-CPR and then were tested on each method at baseline (0), 6, and 18 months after training. The students' performance for at least 90 s of CPR was evaluated based on video and Laerdal Skillreporter Resusci Anne recordings.

RESULTS

The mean number of correct chest compressions delivered per minute trended down over time in STD-CPR (23 +/- 3, 19 +/- 4 , and 15 +/- 3; P = 0.09) but stayed the same in UCC-CPR (43 +/- 9, 38 +/- 7, and 37 +/- 7 = 0.91) at 0, 6, and 18 months, respectively. The mean percentage of chest compressions delivered correctly fell over time in STD-CPR (54 +/- 6%, 35 +/- 6%, and 32 +/- 6%; P = 0.02) but stayed the same in UCC-CPR (34 +/- 5%, 41 +/- 7%, and 38 +/- 8%) at 0, 6, and 18 months, respectively. The number of chest compressions delivered per minute was higher in UCC-CPR at 0, 6, and 18 months (113 versus 44, P < 0.0001; 94 versus 47, P < 0.0001; and 92 versus 44, P < 0.001). The greater number of chest compressions was due to a mean ventilaroty pause of 13-14 s during STD-CPR at all three time points.

CONCLUSIONS

Chest compression performance during STD-CPR declined in repeated testing over 18 months whereas there was minimal decline in chest compressions performance on repeated testing of UCC-CPR. In addition, substantially more chest compressions were delivered during UCC-CPR compared to STD-CPR at all time points primarily because of long pauses accompanying rescue breathing.

Single-rescuer cardiopulmonary resuscitation: ‘two quick breaths’—an oxymoron

The Guidelines 2000 for CPR and ECC recommend for single lay-rescuers performing basic life support, "two quick breaths followed by 15 chest compressions", repeated until professional help arrives. It is uncertain that this can actually be accomplished by the majority of lay rescuers. We evaluated 53 first-year medical students after completing BLS CPR training to determine if they could deliver the goal of 80 compressions per minute when following this AHA BLS recommendation. Alternatively, a simplified technique of uninterrupted chest compression (UCC) BLS CPR was also taught and compared with standard BLS CPR (STD). The mean number of chest compressions/minute delivered with AHA BLS CPR was only 43 +/- 1 immediately after initial training and 49 +/- 2 when tested 6 months later. Uninterrupted chest compression BLS resulted in 113 +/- 2 compressions/min delivered immediately after training and 91 +/- 4 six months later (STD versus UCC; P < 0.0001). The mean length of time needed to provide the two breaths during STD-CPR was 14 +/- 1 and 12 +/- 1s (immediately after first training and six months after training). For STD-CPR, the mean minute ventilation was poor immediately after initial training (3.3 +/- 0.3 l/min) and further declined (1.9 +/- 0.4 l/min) at 6 months (P = 0.003). For single rescuer basic cardiopulmonary resuscitation, motivated BLS CPR-trained medical students take nearly as long as previously reported for middle-aged lay individuals to deliver these "two quick breaths". The "Guidelines 2000" recommendation for "two quick breaths" is an oxymoron, as it averages more than 13s. New recommendations for single-rescuer CPR should be considered that emphasize uninterrupted chest compressions.

A randomized controlled trial of chest compression only CPR for older adults-a pilot study

Older people are trained infrequently in cardiopulmonary resuscitation (CPR), yet are more likely to witness a cardiac arrest. Older people who are CPR trained perform CPR when witnessing a cardiac arrest.

OBJECTIVE

To assess whether elderly adults (>55 years) who receive chest-compression only cardiopulmonary resuscitation (CC-CPR) training display equivalent skill retention rates compared with those who receive traditional CPR instruction. We also identified factors associated with 3 months skill retention at 3 months in both groups.

METHODS

Older adults in a suburban hospital Older Adult Services program were invited to participate in an experimental CPR course. The 2 h course was modelled after the AHA Friends and Family course, and used one of two standardized video scenarios. Seventy four subjects were randomized to CC-CPR (n=36) or traditional CPR (n=38) training. Participation consisted of initial training, followed by a 3 months return videotaped assessment. Three months skill competence was assessed either by consensus between two video evaluators, or the on-site evaluator. Chi square and Kappa tests were used for analysis, and unadjusted odds ratios and 95% confidence intervals are reported.

RESULTS

Skill retention assessments were completed on 29 (81%) CC-CPR and 26 (68%) CPR trainees. Subjects were elderly (71.5+/-6.69 years), and had a high rate of previous CPR training (58.0%). Groups were similar in demographic characteristics. After training, participants exhibited high rates of perceived competence (86.4%), although the overall 3 months skill retention was low (43.6%). CC-CPR training resulted in equivalent skill retention rates as compared with traditional CPR training (51.7 vs. 44.4%; P=0.586). No participant factors were associated with skill retention, including age, previous CPR training, education level, medical history, or perceived physical ability to perform.

CONCLUSION

We identified low rates of CPR skill retention in this elderly population. CC-CPR instruction was associated with equivalent skill retention rates compared with traditional CPR instruction. No demographic factors were associated with successful skill retention.

The respiratory system during resuscitation: a review of the history, risk of infection during assisted ventilation, respiratory mechanics, and ventilation strategies for patients with an unprotected airway

The fear of acquiring infectious diseases has resulted in reluctance among healthcare professionals and the lay public to perform mouth-to-mouth ventilation. However, the benefit of basic life support for a patient in cardiopulmonary or respiratory arrest greatly outweighs the risk for secondary infection in the rescuer or the patient. The distribution of ventilation volume between lungs and stomach in the unprotected airway depends on patient variables such as lower oesophageal sphincter pressure, airway resistance and respiratory system compliance, and the technique applied while performing basic or advanced airway support, such as head position, inflation flow rate and time, which determine upper airway pressure. The combination of these variables determines gas distribution between the lungs and the oesophagus and subsequently, the stomach. During bag-valve-mask ventilation of patients in respiratory or cardiac arrest with oxygen supplementation (> or = 40% oxygen), a tidal volume of 6-7 ml kg(-1) ( approximately 500 ml) given over 1-2 s until the chest rises is recommended. For bag-valve-mask ventilation with room-air, a tidal volume of 10 ml kg(-1) (700-1000 ml) in an adult given over 2 s until the chest rises clearly is recommended. During mouth-to-mouth ventilation, a breath over 2 s sufficient to make the chest rise clearly (a tidal volume of approximately 10 ml kg(-1) approximately 700-1000 ml in an adult) is recommended.

Determinants of physician reluctance to perform mouth-to-mouth resuscitation

OBJECTIVES

Mouth-to-mouth resuscitation (MMR) is widely taught and promoted. The purpose of this study was to better characterize the observation that health professionals are reluctant to perform MMR and to identify determinants of this reluctance.

METHODS

324 residents and faculty at a New York City teaching hospital were anonymously surveyed regarding their reluctance to perform MMR. One year later, medical staff were resurveyed.

RESULTS

Reluctance varied across scenarios: 70-80% of physicians were willing to perform MMR on a newborn or child, 40-50% for an unknown man, and 20-30% for a trauma victim or potentially gay man. Physicians reported very similar percentages for each scenario in the two surveys. Factors associated with MMR reluctance were female gender (OR = 2), resident physician (OR = 2), and higher perceived risk of contracting HIV from MMR (OR = 1.4 per unit on 5-point scale). In the year before the survey, 30% of all respondents witnessed an apneic patient who required MMR for whom ventilation was not provided for at least 2 minutes.

CONCLUSIONS

Many physicians are reluctant to perform MMR. Marked delays in ventilation of apneic patients are occurring.

Obstacles to bystander cardiopulmonary resuscitation in Japan

OBJECTIVE

bystander cardiopulmonary resuscitation (CPR) is performed infrequently in Japan. We conducted this study to identify Japanese attitudes toward the performance of bystander CPR.

METHODS

participants were asked about their willingness to perform CPR with varying scenarios and CPR techniques (mouth-to-mouth ventilation plus chest compression (MMV plus CC) versus chest compression alone (CC)).

RESULTS

a total of 1302/1355 individuals completed the questionnaire, including high school students, teachers, emergency medical technicians, medical nurses, and medical students. About 2% of high school students, 3% of teachers, 26% of emergency medical technicians, 3% of medical nurses and 16% of medical students claimed they would 'definitely' perform MMV plus CC on a stranger. However, 21-72% claimed they would prefer the alternative of performing CC alone. Respondents claimed their unwillingness to perform MMV is not due to the fear of contracting a communicable disease, but the lack of confidence in their ability to perform CPR properly.

CONCLUSION

in all categories of respondents, willingness to perform MMV plus CC for a stranger was disappointingly low. Better training in MMV together with teaching awareness that CC alone can be given should be instituted to maximize the number of potential providers of CPR in the community, even in communities where the incidence of HIV is very low.

Efficacy of chest compression-only BLS CPR in the presence of an occluded airway

Reluctance of the lay public to perform bystander CPR is becoming an increasingly worrisome problem in the USA. Most bystanders who admit such reluctance concede that fear of contagious disease from mouth-to-mouth contact is what keeps them from performing basic life support. Animal models of prehospital cardiac arrest indicates that 24-h survival is essentially as good with chest compression-only CPR as with chest compressions and assisted ventilation. This simpler technique is an attractive alternative strategy for encouraging more bystander participation. Such experimental studies have been criticized as irrelevant however secondary to differences between human and porcine airway mechanics. This study examined the effect of chest compression-only CPR under the worst possible circumstances where the airway was totally occluded. After 6 min of either standard CPR including ventilation with a patent airway or chest compressions-only with a totally occluded airway, no difference in 24 h survival was found (10/10 vs. 9/10). As anticipated arterial blood gases were not as good, but hemodynamics produced were better with chest compression-only CPR (P < 0.05). Chest compression-only CPR, even with a totally occluded airway, is as good as standard CPR for successful outcome following 6.5 min of cardiac arrest. Such a strategy for the first minutes of cardiac arrest, particularly before professional help arrives, has several advantages including increased acceptability to the lay public.

Determinants of reluctance to perform CPR among residents and applicants: the impact of experience on helping behavior

BACKGROUND

Though mouth-to-mouth resuscitation (MMR) is widely endorsed as a useful lifesaving technique, studies have shown that health care professionals are reluctant to perform it. To characterize the circumstances which facilitate this reluctance among physicians, we have surveyed current and future residency trainees regarding attitudes toward providing ventilation by this method to strangers experiencing arrest in the community.

METHODS

A total of 280 categorical emergency medicine (EM) and internal medicine (IM) house officers and respective program applicants at a 655 bed Brooklyn, New York teaching hospital were anonymously surveyed regarding their willingness to attempt resuscitation in five hypothetical scenarios of cardiopulmonary arrest.

RESULTS

A direct relationship was observed between residency training level and reluctance to perform MMR in each scenario. Applicants expressed greater overall willingness to perform MMR than all residents (56 versus 34%, P < 0.00001). Willingness among experienced residents was lower than for junior-level residents (29 versus 40%, P = 0.01). EM and IM physicians were statistically indifferent in their responses. There were no differences in willingness to perform MMR by age in MD applicant or resident groups.

CONCLUSIONS

Many physicians and future doctors are reluctant to perform MMR on arrest victims in the community, a trend that increases in prevalence among those with more residency training. These data support the hypothesis that diminished helping behavior occurs gradually over the training period and may occur as a direct consequence of the training experience. A model for characterizing the elements that make up a rescuer's decision process is proposed.