The International Liaison Committee on Resuscitation (ILCOR)—Past and present

Neonatal resuscitation from a global perspective

The majority of perinatal and neonatal mortality occurs in low-resource settings in low- and middle-income countries. Access and quality of care at delivery are major determinants of the health and survival of newborn infants. Availability of basic neonatal resuscitation care at birth has improved, but basic neonatal resuscitation at birth or high-quality care continues to be inaccessible in some settings, leading to persistently high perinatal and neonatal mortality. Low-resource settings of high-income countries and socially disadvantaged communities also suffer from inadequate access to quality perinatal healthcare. Quality improvement, implementation research, and innovation should focus on improving the quality of perinatal healthcare and perinatal and neonatal outcomes in low-resource settings. The current review presents an update on issues confronting universal availability of optimal resuscitation care at birth and provides an update on ongoing efforts to address them.

Resuscitation 2020: Proceedings From the NeoHeart 2020 International Conference

Resuscitation guidelines are developed and revised by medical societies throughout the world. These guidelines are increasingly based on evidence from preclinical and clinical research. The International Liaison Committee on Resuscitation reviews evidence for each resuscitation practice and provides summary consensus statements that inform resuscitation guideline committees. A similar process is used for different populations including neonatal, pediatric, and adult resuscitation. The NeoHeart 2020 Conference brought together experts in resuscitation to discuss recent evidence and guidelines for resuscitation practices. This review summarizes the main focus of discussion from this symposium.

Neonatal Resuscitation Research Priorities in Low- and Middle-Income Countries

Several critical physiological changes occur during birth. Optimal and timely resuscitation is essential to avoid morbidity and mortality. The International Liaison Committee on Resuscitation (ILCOR) is a multinational committee that publishes evidence-based consensus and treatment recommendations for resuscitation in various scenarios including that for neonatal resuscitation. The majority of perinatal deaths occur in low- and middle-income countries (LMICs); however, there is limited research output from LMICs to generate evidence-based practice recommendations specific for LMICs. The current review identifies key areas of neonatal resuscitation-related research needed from LMICs to inform evidence-based resuscitation of neonates in LMICs.

Dealing with neonatal emergencies in low-resource settings

We describe the development and delivery of neonatal care including trends and impacts of major interventions on neonatal mortality particularly in low-resource settings. Low- and middle-income countries continue to be major contributors to neonatal mortality. Although there has been progress in reducing neonatal mortality, neonatal deaths are contributing an increasing percentage of childhood mortality. Several interventions targeting neonatal care such as neonatal resuscitation and essential newborn care have contributed to improved outcomes. However, there are still many neonatal deaths that are preventable with known effective interventions. This review addresses interventions proven effective in reducing neonatal mortality, challenges to implement them, and future directions of implementing these interventions in low- and middle-income countries.

The International Liaison Committee on Resuscitation-Review of the last 25 years and vision for the future

2017 marks the 25th anniversary of the International Liaison Committee on Resuscitation (ILCOR). ILCOR was formed in 1992 to create a forum for collaboration among principal resuscitation councils worldwide. Since then, ILCOR has established and distinguished itself for its pioneering vision and leadership in resuscitation science. By systematically assessing the evidence for resuscitation standards and guidelines and by identifying national and regional differences, ILCOR reached consensus on international resuscitation guidelines in 2000, and on international science and treatment recommendations in 2005, 2010 and 2015. However, local variation and contextualization of guidelines are evident by subtle differences in regional and national resuscitation guidelines. ILCOR's efforts to date have enhanced international cooperation, and progressively more transparent and systematic collection and analysis of pertinent scientific evidence. Going forward, this sets the stage for ILCOR to pursue its vision to save more lives globally through resuscitation.

Amiodarone Versus Lidocaine for Pediatric Cardiac Arrest Due to Ventricular Arrhythmias: A Systematic Review

OBJECTIVE

We performed a systematic review as part of the International Liaison Committee on Resuscitation process to create a consensus on science statement regarding amiodarone or lidocaine during pediatric cardiac arrest for the 2015 International Liaison Committee on Resuscitation's Consensus on Science and Treatment Recommendations.

DATA SOURCES

Studies were identified from comprehensive searches in PubMed, Embase, and the Cochrane Library.

STUDY SELECTION

Studies eligible for inclusion were randomized controlled and observational studies on the relative clinical effect of amiodarone or lidocaine in cardiac arrest.

DATA EXTRACTION

Studies addressing the clinical effect of amiodarone versus lidocaine were extracted and reviewed for inclusion and exclusion criteria by the reviewers. Studies were rigorously analyzed thereafter.

DATA SYNTHESIS

We identified three articles addressing lidocaine versus amiodarone in cardiac arrest: 1) a prospective study assessing lidocaine versus amiodarone for refractory ventricular fibrillation in out-of-hospital adults; 2) an observational retrospective cohort study of inpatient pediatric patients with ventricular fibrillation or pulseless ventricular tachycardia who received lidocaine, amiodarone, neither or both; and 3) a prospective study of ventricular tachycardia with a pulse in adults. The first study showed a statistically significant improvement in survival to hospital admission with amiodarone (22.8% vs 12.0%; p = 0.009) and a lack of statistical difference for survival at discharge (p = 0.34). The second article demonstrated 44% return of spontaneous circulation for amiodarone and 64% for lidocaine (odds ratio, 2.02; 1.36-3.03) with no statistical difference for survival at hospital discharge. The third article demonstrated 48.3% arrhythmia termination for amiodarone versus 10.3% for lidocaine (p < 0.05). All were classified as lower quality studies without preference for one agent.

CONCLUSIONS

The confidence in effect estimates is so low that International Liaison Committee on Resuscitation felt that a recommendation to use of amiodarone over lidocaine is too speculative; we suggest that amiodarone or lidocaine can be used in the setting of pulseless ventricular tachycardia/ventricular fibrillation in infants and children.

Inotropic Effects of Experimental Hyperthermia and Hypothermia on Left Ventricular Function in Pigs-Comparison With Dobutamine

OBJECTIVES

The results from the recent Targeted Temperature Management trial raised the question whether cooling or merely the avoidance of fever mediates better neurologic outcome in resuscitated patients. As temperature per se is a major determinant of cardiac function, we characterized the effects of hyperthermia (40.5°C), normothermia (38.0°C), and mild hypothermia (33.0°C) on left ventricular contractile function in healthy pigs and compared them with dobutamine infusion.

DESIGN

Animal study.

SETTING

Large animal facility, Medical University of Graz, Graz, Austria.

SUBJECTS

Nine anesthetized and mechanically ventilated closed-chest Landrace pigs (67 ± 2 kg).

INTERVENTIONS

Core body temperature was controlled using an intravascular device. At each temperature step, IV dobutamine was titrated to double maximum left ventricular dP/dt (1.8 ± 0.1 µg/kg/min at normothermia). Left ventricular pressure-volume relationships were assessed during short aortic occlusions. Left ventricular contractility was assessed by the calculated left ventricular end-systolic volume at an end-systolic left ventricular pressure of 100 mm Hg.

MEASUREMENTS AND MAIN RESULTS

Heart rate (98 ± 4 vs 89 ± 4 vs 65 ± 2 beats/min; all p < 0.05) and cardiac output (6.7 ± 0.3 vs 6.1 ± 0.3 vs 4.4 ± 0.2 L/min) decreased with cooling from hyperthermia to normothermia and mild hypothermia, whereas left ventricular contractility increased (left ventricular end-systolic volume at a pressure of 100 mm Hg: 74 ± 5 mL at hyperthermia, 52 ± 4 mL at normothermia, and 41 ± 3 mL at mild hypothermia; all p < 0.05). The effect of cooling on left ventricular end-systolic volume at a pressure of 100 mm Hg (hyperthermia to normothermia: -28% ± 3% and normothermia to mild hypothermia: -20% ± 5%) was of comparable effect size as dobutamine at a given temperature (hyperthermia: -28% ± 4%, normothermia: -27% ± 6%, and mild hypothermia: -27% ± 9%).

CONCLUSIONS

Cooling from hyperthermia to normothermia and from normothermia to mild hypothermia increased left ventricular contractility to a similar degree as a significant dose of dobutamine in the normal porcine heart. These data indicate that cooling can reduce the need for positive inotropes and that lower rather than higher temperatures are appropriate for the resuscitated failing heart.

Changing guidelines of cardiopulmonary resuscitation and basic life support for general dental practitioners and oral and maxillofacial surgeons

INTRODUCTION

Every general dental practitioner and oral and maxillofacial surgeon needs a thorough knowledge of the diagnosis and management of medical emergencies. Cardiopulmonary arrest is the most urgent of emergencies and diagnosis must be done as soon as possible.

PURPOSE

This paper discusses the importance of the International Liaison Committee on Resuscitation which forms the guidelines for cardiopulmonary resuscitation (CPR), highlighting the important changes in the guidelines of CPR from the year 2000 to 2010, the basic sequence of performing CPR and also the role of defibrillation and the use of automated external defibrillators. Finally the five part chain of survival which is of utmost importance to dental health care professionals and oral and maxillofacial surgeons.

CONCLUSION

All dental health care personnel and oral & maxillofacial surgeons should recognize the importance of the changes in the guidelines of CPR, be trained and allowed to use a properly maintained defibrillator, to respond to cardiac arrest victims.

Teleconsultation in pre-hospital emergency medical services: real-time telemedical support in a prospective controlled simulation study

BACKGROUND

Teleconsultation from the scene of an emergency to an experienced physician including real-time transmission of monitoring, audio and visual information seems to be feasible. In preparation for bringing such a system into practice within the research project "Med-on-@ix", a simulation study has been conducted to investigate whether telemedical assistance (TMA) in Emergency Medical Services (EMS) has an impact on compatibility to guidelines and timing.

MATERIAL AND METHODS

In a controlled simulation study 29 EMS teams (one EMS physician, two paramedics) ran through standardized scenarios (STEMI: ST-elevation myocardial infarction; MT: major trauma) on high-fidelity patient simulators with defined complications (treatable clearly following guidelines). Team assignments were randomized and each team had to complete one scenario with and another without TMA. Analysis was based on videotaped scenarios using pre-defined scoring items and measured time intervals for each scenario.

RESULTS

Adherence to treatment algorithms improved using TMA. STEMI: cathlab informed (9/14 vs. 15/15; p=0.0169); allergies checked prior to acetylsalicylic acid (5/14 vs. 13/15; p=0.0078); analgosedation prior to cardioversion (10/14 vs. 15/15; p=0.0421); synchronized shock (6/14 vs. 14/15; p=0.0052). MT: adequate medication for intubation (3/15 vs. 10/14; p=0.0092); mean time to inform trauma centre 547 vs. 189 s (p=0.0001). No significant impairment of performance was detected in TMA groups.

CONCLUSIONS

In simulated setting TMA was able to improve treatment and safety without decline in timing. Nevertheless, further research is necessary to optimize the system for medical, organizational and technical reasons prior to the evaluation of this system in routine EMS.

Out-of-hospital cardiac arrests in young adults in Melbourne, Australia-adding coronial data to a cardiac arrest registry

AIM

We aim to describe the coronial findings of young adults where the out-of-hospital cardiac arrest (OHCA) aetiology was 'presumed cardiac'.

METHODS

Presumed cardiac aetiology OHCAs occurring in young adults aged 16-39 years were identified using the Victorian Ambulance Cardiac Arrest Registry (VACAR) and available coronial findings reviewed.

RESULTS

We identified 841 young adult OHCAs where the Utstein aetiology was 'presumed cardiac'. Of these 740 died and 572 (77%) OHCAs were matched to coroner's findings. On review of the coroner's cause of death, 230 (40.2%) had a 'confirmed cardiac' aetiology, 221 (38.6%) were proven 'non-cardiac', 97 (17%) were inconclusive and 24 (4.2%) cases remained 'open'. 'Confirmed cardiac' causes of OHCA were ischemic heart disease (n=126, 55%), cardiomegaly (n=26, 11.3%), cardiomyopathy (n=25, 11%), congenital heart disease (n=15, 6.5%), cardiac tamponade due to dissecting thoracic aorta aneurysm (n=10, 4.3%), myocarditis (n=8, 3.5%), arrhythmia (n=7, 3%), others (n=13, 5.7%). 'Non-cardiac' causes of OHCA were epilepsy/sudden unexplained death in epilepsy (SUDEP) (n=56, 25%), pulmonary embolism (n=29, 13%), subarachnoid haemorrhage (n=17, 7.7%), other intracranial bleed (n=7, 3.2%), pneumonia (n=17, 7.7%), DKA (n=16, 7.2%), other complications of diabetes mellitus (n=8, 3.6%), complications of obesity (n=9, 4%), haemorrhage (n=12, 5.4%), sepsis (n=8, 3.6%), peritonitis (n=6, 2.7%), aspiration (n=6, 2.7%), renal failure (n=5, 2.3%), asthma (n=5, 2.3%), complications of anorexia (n=3) and alcohol abuse (n=2), thyrotoxicosis (n=2), meningitis (n=1) and others (n=12). Compared with coroner's diagnosed 'non-cardiac' OHCAs, 'confirmed cardiac' were more likely to be witnessed (41% vs 23%, p≤0.01), receive bystander CPR (35% vs 20%, p≤0.001), have a shockable rhythm (27% vs 6.3%, p<0.001) and have EMS attempted resuscitation (62% vs 44%, p<0.001).

DISCUSSION

Linking OHCA registries with coronial databases for aetiology of the arrest will improve the quality of the data and should be considered by all OHCA registries, particularly for young adult OHCA.

[Life-threatening brady- and tachyarrhythmias]

Bradycardic (heart rate<50/min) and tachycardic heart rhythm disturbances (100/min) require rapid therapeutic strategies. Supraventricular tachycardias (SVT) are sinus tachycardia, atrial tachycardia, AV-nodal reentrant tachycardia and tachycardia due to accessory pathways. Mostly SVT are characterized by small QRS complexes (QRS width<0.12 ms). It is essential to evaluate the arrhythmia history, to perform a good physical examination and to exactly analyze the 12-lead electrocardiogram. An exact diagnosis is then possible in >90% of SVT patients. Ventricular tachycardias have a broad QRS complex (>or=0.12 s), ventricular flutter and ventricular fibrillation are associated with chaotic electrophysiologic findings. For acute therapy, we will present the new concept of the "5A" that includes adenosine, adrenaline, ajmaline, amiodarone and atropine. Additional "B, C and D strategies" include betablocking agents, cardioversion as well as defibrillation. The "5A" concept allows a safe and effective antiarrhythmic treatment of all bradycardic and tachycardic arrhythmias as well as asystolia.

Compression-only CPR or standard CPR in out-of-hospital cardiac arrest

BACKGROUND

Emergency medical dispatchers give instructions on how to perform cardiopulmonary resuscitation (CPR) over the telephone to callers requesting help for a patient with suspected cardiac arrest, before the arrival of emergency medical services (EMS) personnel. A previous study indicated that instructions to perform CPR consisting of only chest compression result in a treatment efficacy that is similar or even superior to that associated with instructions given to perform standard CPR, which consists of both compression and ventilation. That study, however, was not powered to assess a possible difference in survival. The aim of this prospective, randomized study was to evaluate the possible superiority of compression-only CPR over standard CPR with respect to survival.

METHODS

Patients with suspected, witnessed, out-of-hospital cardiac arrest were randomly assigned to undergo either compression-only CPR or standard CPR. The primary end point was 30-day survival.

RESULTS

Data for the primary analysis were collected from February 2005 through January 2009 for a total of 1276 patients. Of these, 620 patients had been assigned to receive compression-only CPR and 656 patients had been assigned to receive standard CPR. The rate of 30-day survival was similar in the two groups: 8.7% (54 of 620 patients) in the group receiving compression-only CPR and 7.0% (46 of 656 patients) in the group receiving standard CPR (absolute difference for compression-only vs. standard CPR, 1.7 percentage points; 95% confidence interval, -1.2 to 4.6; P=0.29).

CONCLUSIONS

This prospective, randomized study showed no significant difference with respect to survival at 30 days between instructions given by an emergency medical dispatcher, before the arrival of EMS personnel, for compression-only CPR and instructions for standard CPR in patients with suspected, witnessed, out-of-hospital cardiac arrest. (Funded by the Swedish Heart–Lung Foundation and others; Karolinska Clinical Trial Registration number, CT20080012.)

Body temperature effects on lung injury in ventilated preterm lambs

AIMS

Mechanical ventilation causes lung injury in premature infants. Hypothermia may protect against and hyperthermia may augment lung injury. We tested the effects of hypo- and hyperthermia on ventilation induced acute lung injury in preterm lambs.

METHODS

Twin sheep fetuses at 128 d GA (term 150 d) were surgically delivered and randomized to unventilated control (UVC), normothermia (38-39 degrees C) without lung injury (NTNI), or to 1 of 3 injurious ventilation groups: hypothermic (33-34 degrees C, LT), normothermic (38-39 degrees C, NT) or hyperthermic (40-41 degrees C, HT). NT, LT and HT groups had 15 min of injurious ventilation (PEEP 0 cmH(2)O, V(T) escalation to 15 mL/kg) following delivery and prior to surfactant. The animals were then gently ventilated (PEEP 5cmH(2)O, V(T) 7.5 mL/kg) for 2h 45 min. NTNI lambs received surfactant at birth prior to gentle ventilation. The lambs were then euthanized, and bronchoalveolar lavage (BAL) fluid and lung tissue were used to evaluate lung injury, inflammatory cell counts, inflammatory markers and cytokine mRNA.

RESULTS

Target temperatures were achieved by 15 min of age and maintained for 3h. All ventilated groups had increased BAL protein, lung inflammation and increased cytokine mRNA. HT animals developed acidosis, premature death, pneumothoraces, impaired lung function and increased inflammatory mRNA expression. LT animals remained clinically stable without pneumothoraces or death, had improved ventilatory efficiency and trended toward lower inflammatory mRNA expression than NT animals.

CONCLUSION

Hyperthermia exacerbated ventilator induced lung injury, while hypothermia may protect against lung injury in the preterm lamb.

Undergraduate medical education in emergency medical care: a nationwide survey at German medical schools

Background

Since June 2002, revised regulations in Germany have required "Emergency Medical Care" as an interdisciplinary subject, and state that emergency treatment should be of increasing importance within the curriculum. A survey of the current status of undergraduate medical education in emergency medical care establishes the basis for further committee work.

Methods

Using a standardized questionnaire, all medical faculties in Germany were asked to answer questions concerning the structure of their curriculum, representation of disciplines, instructors' qualifications, teaching and assessment methods, as well as evaluation procedures.

Results

Data from 35 of the 38 medical schools in Germany were analysed. In 32 of 35 medical faculties, the local Department of Anaesthesiology is responsible for the teaching of emergency medical care; in two faculties, emergency medicine is taught mainly by the Department of Surgery and in another by Internal Medicine. Lectures, seminars and practical training units are scheduled in varying composition at 97% of the locations. Simulation technology is integrated at 60% (n = 21); problem-based learning at 29% (n = 10), e-learning at 3% (n = 1), and internship in ambulance service is mandatory at 11% (n = 4). In terms of assessment methods, multiple-choice exams (15 to 70 questions) are favoured (89%, n = 31), partially supplemented by open questions (31%, n = 11). Some faculties also perform single practical tests (43%, n = 15), objective structured clinical examination (OSCE; 29%, n = 10) or oral examinations (17%, n = 6).

Conclusion

Emergency Medical Care in undergraduate medical education in Germany has a practical orientation, but is very inconsistently structured. The innovative options of simulation technology or state-of-the-art assessment methods are not consistently utilized. Therefore, an exchange of experiences and concepts between faculties and disciplines should be promoted to guarantee a standard level of education in emergency medical care.

The simulated delivery-room environment as the future modality for acquiring and maintaining skills in fetal and neonatal resuscitation

The science underlying neonatal resuscitation is growing exponentially in quantity and quality. So, too, is the knowledge of effective methodologies that facilitate acquisition and maintenance of the cognitive, technical, and behavioral skills necessary to for successful resuscitation of the newborn. One of these methodologies, simulation-based training, offers many advantages over more traditional methodologies: By providing key visual, auditory, and tactile cues it creates a high level of physical, biological, and psychological fidelity to the real environment and thus is able to elicit realistic responses from trainees. Training scenarios coupled with debriefings (where discussion of what went well and what could be improved upon occur in a nonjudgmental fashion) provide rich learning experiences that rival or exceed those in the real clinical environment. Simulation-based training will likely become the standard for not only routine training but also high-stakes assessment such as licensure and board certification.

[Prehospital care of acute coronary syndrome by anaesthetists. Prospective comparison with the care standards of cardiologists]

BACKGROUND

Prehospital treatment of acute coronary syndrome (ACS) by anaesthetists acting in physician staffed emergency medical service (EMS) was compared with that of the gold standard of cardiologists.

METHODS

Prospectively 599 patients with assumed ACS were traced. Prehospital diagnosis and therapy were compared with re-evaluation of ECGs and diagnosis on hospital discharge.

RESULTS

In the case of ST-segment elevating myocardial infarction (STEMI) anaesthetists diagnosed 84% of cases correctly and cardiologists in 94% (p=0.048). False positive diagnoses were given in 11% by anaesthetists versus 5% by cardiologists (p=0.31). Anaesthetists accompanied all patients with instable angina versus 94% by cardiologists (p=0.06). Anaesthetists achieved 82% of patients to be pain-free versus 73% of cardiologists (p=0.01). Mortality until discharge was identical for the two groups (8.2%).

CONCLUSION

In prehospital management of ACS cardiologists showed higher diagnostic competence, whereas anaesthetists revealed a greater degree of therapeutic caution. Patient mortality was not influenced.

Basics in advanced life support: a role for download audit and metronomes

An intention in 2003 to undertake a multicentre trial in the United Kingdom of compressions before and after defibrillation could not be realized because of concerns at the time in relation to informed consent. Instead, the new protocol was introduced in one ambulance service, ahead of the 2005 Guidelines, with greater emphasis on compressions. The results were monitored by analysis of electronic ECG downloads. Deficiencies in the standard of basic life support were identified but were not unique to our service. The introduction of metronomes and the provision of feedback to crews led to major improvements in performance. Our experience has implications for the emergency pre-hospital care of cardiac arrest.

[Update on recommendations for adult basic cardiopulmonary resuscitation]

One of the most urgent situations faced by nurses is cardiac arrest. Knowledge of cardiopulmonary resuscitation (CPR) is essential for survival after intra-or out-of-hospital cardiac arrest. Two of the main factors predicting survival after a cardiopulmonary arrest are the immediate start of CPR and early activation of the survival chain. In 2005 The European Resuscitation Council published new recommendations on CPR. The changes center on simplification of the protocol, giving greater importance to chest compressions than to mouth-to-mouth breath resuscitation. After checking that the victim is not breathing, 30 compressions must be immediately given. The first 2 rescue breaths and carotid pulse checking have been eliminated. The current recommended ratio of chest compressions-breaths is 30:2.

Cost-efficiency assessment of Advanced Life Support (ALS) courses based on the comparison of advanced simulators with conventional manikins

BACKGROUND

Simulation is an essential tool in modern medical education. The object of this study was to assess, in cost-effective measures, the introduction of new generation simulators in an adult life support (ALS) education program.

METHODS

Two hundred fifty primary care physicians and nurses were admitted to ten ALS courses (25 students per course). Students were distributed at random in two groups (125 each). Group A candidates were trained and tested with standard ALS manikins and Group B ones with new generation emergency and life support integrated simulator systems.

RESULTS

In group A, 98 (78%) candidates passed the course, compared with 110 (88%) in group B (p < 0.01). The total cost of conventional courses was euro 7689 per course and the cost of the advanced simulator courses was euro 29034 per course (p < 0.001). Cost per passed student was euro 392 in group A and euro 1320 in group B (p < 0.001).

CONCLUSION

Although ALS advanced simulator systems may slightly increase the rate of students who pass the course, the cost-effectiveness of ALS courses with standard manikins is clearly superior.

Video-recording and time-motion analyses of manual versus mechanical cardiopulmonary resuscitation during ambulance transport

INTRODUCTION

The quality of cardiopulmonary resuscitation (CPR) plays a crucial role in saving lives from out-of-hospital cardiac arrest (OHCA). Previous studies have identified sub-optimal CPR quality in the prehospital settings, but the causes leading to such deficiencies were not fully elucidated.

OBJECTIVE

This prospective study was conducted to identify operator- and ambulance-related factors affecting CPR quality during ambulance transport; and to assess the effectiveness of mechanical CPR device in such environment.

MATERIALS AND METHODS

A digital video-recording system was set up in two ambulances in Taipei City to study CPR practice for adult, non-traumatic OHCAs from January 2005 to March 2006. Enrolled patients received either manual CPR or CPR by a mechanical device (Thumper). Quality of CPR in terms of (1) adequacy of chest compressions, (2) instantaneous compression rates, and (3) unnecessary no-chest compression interval, was assessed by time-motion analysis of the videos.

RESULTS

A total of 20 ambulance resuscitations were included. Compared to the manual group (n=12), the Thumper group (n=8) had similar no-chest compression interval (33.40% versus 31.63%, P=0.16); significantly lower average chest compression rate (113.3+/-47.1 min(-1) versus 52.3+/-14.2 min(-1), P<0.05), average chest compression rate excluding no-chest compression interval (164.2+/-43.3 min(-1) versus 77.2+/-6.9 min(-1), P<0.05), average ventilation rate (16.1+/-4.9 min(-1) versus 11.7+/-3.5 min(-1), P<0.05); and longer no-chest compression interval before getting off the ambulance (5.7+/-9.9s versus 18.7+/-9.1s, P<0.05). The majority of the no-chest compression interval was considered operator-related; only 15.3% was caused by ambulance related factors.

CONCLUSIONS

Many unnecessary no-chest compression intervals were identified during ambulance CPR, and most of this was operator, rather than ambulance related. Though a mechanical device could minimise the no-chest compression intervals after activation, it took considerable time to deploy in a system with short transport time. Human factors remained the most important cause of poor CPR quality. Ways to improve the CPR quality in the ambulance warrant further study.

[Public access defibrillation. Limited use by trained first responders and laymen]

As ventricular fibrillation is the most frequent initial heart rhythm causing out-of-hospital sudden cardiac arrest, defibrillation is of essential significance. Automated external defibrillators (AEDs) have been available for some years and as a result defibrillation can be carried out by individuals other than physicians and healthcare providers such as trained first responders and untrained lay rescuers. This so-called public access defibrillation nourished hope of progress in the treatment of sudden cardiac arrest. However, several limitations exist, such as low frequency of sudden cardiac arrest in public, rare use of publicly placed AEDs, low cost effectiveness, legal requirements and insufficient public willingness to help. Due to these restrictions of public access defibrillation other measures are more promising than the attempt at general distribution of AEDs. These measures are primary or secondary prophylaxis of sudden cardiac arrest, general knowledge of adequate activation of emergency medical services, implementation of first responder teams equipped with AEDs and particularly a better education in and application of the well-established principles of cardiopulmonary resuscitation.