Changing EMS dispatcher CPR instructions to 400 compressions before mouth-to-mouth improved bystander CPR rates

2024 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the eighth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recent published resuscitation evidence reviewed by the International Liaison Committee on Resuscitation task force science experts. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research.

Out-of-hospital cardiac arrests in Victoria, 2003-2022: retrospective analysis of Victorian Ambulance Cardiac Arrest Registry data

OBJECTIVES

To examine changes in out-of-hospital cardiac arrest (OHCA) characteristics and outcomes during 2003-2022, and 12-month outcomes for people who experienced OHCA during 1 January 2010 - 30 June 2022.

STUDY DESIGN

Retrospective observational study; analysis of Victorian Ambulance Cardiac Arrest Registry (VACAR) data.

SETTING, PARTICIPANTS

OHCA events in Victoria not witnessed by emergency medical services personnel, 1 January 2003 - 31 December 2022.

MAIN OUTCOME MEASURES

Crude and age-standardised annual OHCA incidence rates; survival to hospital discharge.

RESULTS

Of 102 592 OHCA events included in our analysis, 67 756 were in men (66.3%). The age-standardised incidence did not change significantly across the study period (2003: 89.1 cases, 2022: 91.2 cases per 100 000 population; for trend: P = 0.50). The proportion of OHCA cases with attempted resuscitation by emergency medical services in which bystanders attempted cardio-pulmonary resuscitation increased from 40.3% in 2003/2004 to 72.2% in 2021/2022, and that of public access defibrillation from 0.9% to 16.1%. In the Utstein comparator group (witnessed OHCA events in which the initial cardiac rhythm was ventricular fibrillation or ventricular tachycardia, with attempted resuscitation by emergency medical services), the odds of survival to hospital discharge increased during 2003-2022 (adjusted odds ratio (aOR), 3.08; 95% confidence interval [CI], 2.22-4.27); however, the odds of survival was greater than in 2012 only in 2018 (aOR, 1.37; 95% CI, 1.04-1.80) and 2019 (aOR, 1.68; 95% CI, 1.28-2.21). The COVID-19 pandemic was associated with reduced odds of survival (aOR, 0.63; 95% CI, 0.54-0.74). Of 3161 people who survived OHCA and participated in 12-month follow-up, 1218 (38.5%) reported full health according to the EQ-5D.

CONCLUSION

Utstein survival to hospital discharge increased threefold during 2003-2022, and the proportions of cases in which bystanders provided cardio-pulmonary resuscitation or public access defibrillation increased. The COVID-19 pandemic was associated with a substantial reduction in survival, and new strategies are needed to improve outcomes.

2024 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the eighth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recent published resuscitation evidence reviewed by the International Liaison Committee on Resuscitation task force science experts. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research.

YouTube as a Source of Information in Trauma Management for ATLS (10th Edition) Guidelines: Evaluation of Trauma Management Videos on YouTube

Background: Trauma is one of the leading causes of mortality worldwide, and online platforms have become essential sources of information for trauma management. YouTube can play a significant role in helping people access medical information. Methods: YouTube was searched using the keywords management of trauma and assessment of trauma to identify relevant videos. Two authors independently evaluated the videos according to the ATLS (10th edition) guidelines, the modified DISCERN (m-DISCERN) scale, and the Global Quality Scale (GQS) criteria. The videos that met the study criteria were evaluated based on the provider, video length, and view count. Results: Out of 939 videos, 667 were excluded resulting in 272 videos included in the study. According to the ATLS (10th edition) guidelines, the median score for videos was 8 (IQR 7-8). Videos uploaded by official institutions and healthcare professionals received higher scores than from uncertain sources (p = 0.003). According to the GQS, 86% of the videos were low or moderate quality; uncertain sources uploaded 78% of low-quality videos. Conclusion: YouTube is an information source about trauma management that contains videos of varying quality and has a broad audience. Official institutions and healthcare professionals should be aware of this evolving technology and publish up-to-date, accurate content to increase awareness about trauma management and help patients distinguish helpful information from misleading content.

Interventions to optimize dispatcher-assisted CPR instructions: A scoping review

Aim

To review and summarize existing literature and knowledge gaps regarding interventions that have been tested to optimize dispatcher-assisted CPR (DA-CPR) instruction protocols for out-of-hospital cardiac arrest (OHCA).

Methods

This scoping review was undertaken by an International Liaison Committee on Resuscitation (ILCOR) Basic Life Support scoping review team and guided by the ILCOR methodological framework and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). Studies were eligible for inclusion if they were published in peer-reviewed journals and evaluated interventions used to improve DA-CPR. The search was carried out in MEDLINE, EMBASE, Education Resources Information Center (ERIC), PsycINFO, the Cochrane Library, Evidence Based Medicine (EBM) Reviews, and the Campbell Library from 2000 to December 18, 2023.

Results

After full text review, 31 studies were included in the final review. The interventions reviewed were use of video at the scene (n = 9), changes in terminology about compressions (n = 6), implementation of novel DA-CPR protocols (n = 4), advanced dispatcher training (n = 3), centralization of the dispatch center (n = 2), use of metronome or varied metronome rates (n = 2), change in CPR sequence and compression ratio (n = 1), animated audio-visual recording (n = 1), pre-recorded instructions vs. conversational live instructions (n = 1), inclusion of "undress patient" instructions (n = 1), and specific verbal encouragement (n = 1). Studies ranged in methodology from registry studies to randomized clinical trials with the majority being observational studies of simulated EMS calls for OHCA. Outcomes were highly variable but included rates of bystander CPR, confidence & willingness to perform CPR, time to initiation of bystander CPR, bystander CPR quality (including CPR metrics: chest compression depth and rate; chest compression fraction; full chest recoil, ventilation rate, overall CPR competency), rates of automated external defibrillator (AED) use, return of spontaneous circulation (ROSC) and survival. Overall, all interventions seem to be associated with potential improvement in bystander CPR and CPR metrics.

Conclusion

There appears to be trends towards improvement on key outcomes however more research is needed. This scoping review highlights the lack of high-quality clinical research on any of the tested interventions to improve DA-CPR. There is insufficient evidence to explore the effectiveness of any of these interventions via systematic review.

Sex disparities in bystander defibrillation for out-of-hospital cardiac arrest

Background

Previous studies have suggested that females experiencing out-of-hospital cardiac arrest (OHCA) receive lower rates of both bystander cardiopulmonary resuscitation (CPR) and defibrillation compared to males. Whether this disparity has improved over time is unknown.

Methods

A state-wide OHCA registry in Victoria, Australia collected data over twenty years (2002-2021) regarding rates of bystander interventions in OHCA. Characteristics and outcomes of each OHCA were compared with logistic regression according to sex and time (defined in two-year periods).

Results

32,502 OHCAs were included (69.7% male). Both bystander CPR and defibrillation rates increased for females over time (p < 0.0001). There was no sex disparity in receipt of bystander CPR after adjustment for baseline differences. Females were less likely than males to receive bystander defibrillation, with sex disparity increasing from 2010 onwards (adjOR 0.26 (95%CI 0.09-0.80) in 2020-21 for females compared to males).

Conclusion

Initiatives to increase bystander CPR and defibrillation have resulted in higher overall rates of bystander interventions in the last two decades and no significant sex differences in provision of bystander CPR. However, females receive less bystander defibrillation than males, and sex disparity is increasing. Strategies to promote bystander defibrillation in females experiencing OHCA with a shockable rhythm should be a priority.

Comparison of two infant cardiopulmonary resuscitation techniques explained by phone in a non-health professionals' population: Two-thumbs encircling hand technique vs. two-fingers technique, a randomised crossover study in a simulation environment

BACKGROUND

Paediatric out-of-hospital cardiac arrest (OHCA) is the reason for an emergency call in approximately 8/100,000 person-years. Improvement of OHCA resuscitation needs a quality chain of survival and a rapid start of resuscitation. The aim of this study was to compare the efficacy of two resuscitation techniques provided on a mannequin, the two-fingers technique (TFT) and the two-thumbs encircling hand technique (TTHT), explained by a trained emergency call responder on the phone in a population of non-health professionals.

METHODS

We conducted a randomised crossover study in the simulation lab of a University Hospital. The participants included in the study were non-health professional volunteers of legal age. The participants were assigned (1:1 ratio) to two groups: group A: TFT then TTHT, group B: TTHT then TFT. Scenario and techniques were discovered during the evaluation.

RESULTS

Thirty-five volunteers were randomised before the sessions and 33 ultimately came to the simulation lab. We found a better median QCPR global score during TTHT sessions than during TFT sessions (74 vs. 59, P = 0.046). Linear mixed models showed that the TTHT method was the only variable associated with a better QCPR global score [model 1: β = 14.3; 95% confidence interval (CI), 2.4-26.2; model 2: β = 14.5; 95% CI, 2.5-26.6].

CONCLUSION

Our study showed the superiority of TTHT for infant CPR performed by non-health professionals when an emergency call responder advised them over the phone. It seemed to be the best technique for a solo rescuer regardless of previous training.

A scoping review to determine the barriers and facilitators to initiation and performance of bystander cardiopulmonary resuscitation during emergency calls

Background

To maximise out-of-hospital cardiac arrest (OHCA) patients' survival, bystanders should perform continuous, good quality cardiopulmonary resuscitation (CPR) until ambulance arrival.

Objectives

To identify published literature describing barriers and facilitators between callers and call-takers, which affect initiation and performance (continuation and quality) of bystander CPR (B-CPR) throughout the OHCA emergency call.

Eligibility criteria

Studies were included if they reported on the population (emergency callers and call-takers), concept (psychological, physical and communication barriers and facilitators impacting the initiation and performance of B-CPR) and context (studies that analysed OHCA emergency calls).

Sources of evidence

Medline, CINAHL, Cochrane CENTRAL, Embase, Scopus and ProQuest were searched from inception to 9 March 2022.

Charting methods

Study characteristics were extracted and presented in a narrative format accompanied by summary tables.

Results

Thirty studies identified factors that impacted B-CPR initiation or performance during the emergency call. Twenty-eight studies described barriers to the provision of CPR instructions and CPR initiation, with prominent themes being caller reluctance (psychological), physical ability (physical), and callers hanging up the phone prior to CPR instructions (communication). There was little evidence examining barriers and facilitators to ongoing CPR performance (2 studies) or CPR quality (2 studies).

Conclusions

This scoping review using emergency calls as the source, described barriers to the provision of B-CPR instructions and B-CPR initiation. Further research is needed to explore facilitators and barriers to B-CPR continuation and quality throughout the emergency call, and to examine the effectiveness of call-taker strategies to motivate callers to perform B-CPR.

Ambulance management of patients with penetrating truncal trauma and hypotension in Melbourne, Australia

OBJECTIVE

Penetrating truncal trauma with hypotension is uncommon in Australia. Current pre-hospital clinical practice guidelines based on overseas studies recommend expedited transport to definitive trauma care and that i.v. fluid should only be administered to maintain palpable blood pressure.

METHODS

A retrospective review included all adult patients with penetrating truncal trauma and hypotension (systolic blood pressure <90 mmHg) attended by emergency medical services in Victoria between January 2006 and December 2018. Patient pre-hospital characteristics and hospital outcomes are described using descriptive statistics. Predictors of fluid resuscitation and mortality were examined using logistic regression analyses.

RESULTS

Between 2006 and 2018 there were 101 hypotensive, penetrating truncal injury major trauma patients in Melbourne, Victoria transported by road ambulance to a major trauma service. The median age of these patients was 38 years (interquartile range [IQR] 27-50) and 85% were male. Median scene time was 16.6 min (IQR 12-26) and median pre-hospital time was 53.0 min (IQR 38-66). Intravenous fluid resuscitation was given in 54.5% of cases. The mechanism of injury was stabbing in 91.1% and gunshot wound in 8.9%. Urgent surgery was required in 72.3% of cases, 32.7% of patients were admitted to the intensive care unit and there were eight deaths (8.3%).

CONCLUSION

Penetrating truncal trauma with hypotension is rare in Melbourne, Australia with most patients having the injury caused by stabbing rather than shooting. Compared with outcomes reported in the USA and Europe, the mortality rate is low.

Australia's awareness of cardiac arrest and rates of CPR training: results from the Heart Foundation's HeartWatch survey

OBJECTIVE

We aimed to provide the first national estimates of cardiopulmonary resuscitation (CPR) training and awareness of cardiac arrest.

DESIGN

A retrospective analysis of a national cross-sectional survey was undertaken. Data were collected online from adults in July 2017 as part of the Heart Foundation of Australia's HeartWatch survey. We used logistic regression to examine demographic factors associated with CPR training.

PARTICIPANTS

A national cohort was invited to participate in the survey using purposive, non-probability sampling methods with quotas for age, gender and area of residence, in order to reflect the wider Australian population. The final sample consisted of 1076 respondents.

MAIN OUTCOME MEASURE

To determine an estimation of the prevalence of cardiac arrest awareness and CPR training at a national level and the relationship of training to demographic factors.

RESULTS

The majority (76%) of respondents were born in Australia with 51% female and 66% aged between 35 and 64 years. Only 16% of respondents could identify the difference between a cardiac arrest and a heart attack. While 56% reported previous CPR training, only 22% were currently trained (within 1 year). CPR training was associated with younger age (35 to 54 years) (OR 1.45, 95% CI 1.06 to 2.0), being born in Australia (OR 1.59, 95% CI 1.17 to 2.17) and higher levels of education (university, OR 1.86, 95% CI 1.35 to 2.57). CPR training increased confidence in respondents ability to perform effective CPR and use a defibrillator. Lack of CPR training was the most common reason why respondents would not provide CPR to a stranger.

CONCLUSIONS

There is a need to improve the community's understanding of cardiac arrest, and to increase awareness and training in CPR. CPR training rates have not changed over the past decades-new initiatives are needed.

'We're going to do CPR': A linguistic study of the words used to initiate dispatcher-assisted CPR and their association with caller agreement

BACKGROUND

In emergency ambulance calls for out-of-hospital cardiac arrest (OHCA), dispatcher-assisted cardiopulmonary resuscitation (CPR) plays a crucial role in patient survival. We examined whether the language used by dispatchers to initiate CPR had an impact on callers' agreement to perform CPR.

METHODS

We analysed 424 emergency calls relating to cases of paramedic-confirmed OHCA where OHCA was recognised by the dispatcher, the caller was with the patient, and resuscitation was attempted by paramedics. We investigated the linguistic choices used by dispatchers to initiate CPR, and the impact of those choices on caller agreement to perform CPR.

RESULTS

Overall, CPR occurred in 85% of calls. Caller agreement was low (43%) when dispatchers used terms of willingness ("do you want to do CPR?"). Caller agreement was high (97% and 84% respectively) when dispatchers talked about CPR in terms of futurity ("we are going to do CPR") or obligation ("we need to do CPR"). In 38% (25/66) of calls where the caller initially declined CPR, the dispatcher eventually secured their agreement by making several attempts at initiating CPR.

CONCLUSION

There is potential for increased agreement to perform CPR if dispatchers are trained to initiate CPR with words of futurity and/or obligation.

Laypeople roles at road traffic crash scenes: a systematic review

This study aimed to identify the roles of laypeople at road traffic injuries (RTIs). A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The key words of 'laypeople', 'layman', 'layperson', 'bystander', 'first responder', 'lay first responder', 'road traffic', 'road traffic injury', 'crash injury', 'crash scene', 'emergency', 'trauma care', and 'prehospital trauma care' were used in combination with the Boolean operators OR and AND. We did electronic search on Google Scholar, PubMed, ISI Web of Science, CINAHL, Science Direct, Scopus, ProQuest. Based on the reviewed studies, some factors such as cultural conditions, knowledge, relief agencies, and demographic factors affect the interventions of laypeople at the crash scene in functional areas. Regarding the permanent presence of people at the crash scene, the present study can provide an opportunity to reduce different side effects of RTIs imposed on the society.

Identifying barriers to the provision of bystander cardiopulmonary resuscitation (CPR) in high-risk regions: A qualitative review of emergency calls

INTRODUCTION

Understanding regional variation in bystander cardiopulmonary resuscitation (CPR) is important to improving out-of-hospital cardiac arrest (OHCA) survival. In this study we aimed to identify barriers to providing bystander CPR in regions with low rates of bystander CPR and where OHCA was recognised in the emergency call.

METHODS

We retrospectively reviewed emergency calls for adults in regions of low bystander CPR in the Australian state of Victoria. Included calls were those where OHCA was identified during the call but no bystander CPR was given. A thematic content analysis was independently conducted by two investigators.

RESULTS

Saturation of themes was reached after listening to 139 calls. Calls progressed to the point of compression instructions before EMS arrival in only 26 (18.7%) of cases. Three types of barriers were identified: procedural barriers (time lost due to language barriers and communication issues; telephone problems), CPR knowledge (skill deficits; perceived benefit) and personal factors (physical frailty or disability; patient position; emotional factors).

CONCLUSION

A range of factors are associated with barriers to delivering bystander CPR even in the presence of dispatcher instructions - some of which are modifiable. To overcome these barriers in high-risk regions, targeted public education needs to provide information about what occurs in an emergency call, how to recognise an OHCA and to improve CPR knowledge and skills.

A randomized comparison trial of two and four-step approaches to teaching Cardio-Pulmonary Reanimation

Background and aim of the work: The treatment of cardiac arrest in an extra-hospital environment improves with the increase in the number of people able to establish an early Cardio-Pulmonary Reanimation (CPR). The main aim of the study was to assess the validity of the two-step method in case of prolonged CPR. Methods: A randomized comparison study was conducted in the University Nursing School of a Northern Italian town, during the 2015/16 academic year, among 60 students, to teach them CPR techniques, through two different teaching methods (4-step and the 2-step of CPR training). The effectiveness of the maneuvers performed on mannequins equipped with skill-meter was verified. Results: Our study did not highlight any significant difference between the two methods of CPR training. The comparison between the two methods regarding their efficacy in practical teaching of CPR, highlighted by this study, proved the validity of both the 4-minute continuous method (1st method) and the 30:2 method (2nd method). Conclusions: The results of the study showed no differences between the 2-step and the 4-step methods, in the effectiveness of cardiac massage. The correct execution of chest compressions during a CPR is the key to increase the patient’s chances of rescue. Research has shown that any interruption in the execution of chest compressions, leads to a progressive reduction of the effectiveness of cardiac massage, with negative consequences on the prognosis of the patient undergoing at CPR.

The Effect of Telephone Advice on Cardiopulmonary Resuscitation (CPR) on the Rate of Bystander CPR in Out-of-Hospital Cardiopulmonary Arrest in a Typical Urban Area

Introduction

The frequency of telephone advice for cardiopulmonary resuscitation (T-CPR) and its effect are unclear. We have few data concerning how many persons who are willing to perform CPR under the setting of the T-CPR system. Most of these data were from action reports in the pre-hospital EMS records. Methods: This study was a population-based observational case series of out-of-hospital cardiopulmonary arrest (OHCPA). The primary outcome was the acceptability of a bystander to perform CPR according to T-CPR. In our emergency department, one medical doctor interviewed the bystanders regarding T-CPR and CPR; this doctor was devoted to obtaining information from the patients.

Results

Of the 803 patients in, T-CPR advice was provided in 47% and CPR was actually performed in 47% independent of T-CPR guidance. Of the 373 cases in which lay persons received T-CPR, 95% provided CPR. Dispatchers could more easily provide T-CPR to family members compared with friends and passengers. Twenty-one percent of callers made emergency calls after consulting with others (indirect call). In non-traumatic victims who underwent bystander CPR, 43% experienced the return of spontaneous circulation, and 5% were discharged with a mild disorder or no neurological abnormality.

Conclusions

We conclude that 95% of bystanders are willing to perform CPR under the T-CPR system, but we cannot conclude that bystander CPR may not affect the survival rate. These findings indicate that bystanders should be guided with T-CPR. (Hong Kong j.emerg. med. 2016;23:220-226)

Regions With Low Rates of Bystander Cardiopulmonary Resuscitation (CPR) Have Lower Rates of CPR Training in Victoria, Australia

Background

Bystander cardiopulmonary resuscitation (CPR) more than doubles the chance of surviving an out‐of‐hospital cardiac arrest. Recent data have shown considerable regional variation in bystander CPR rates across the Australian state of Victoria. This study aims to determine whether there is associated regional variation in rates of CPR training and willingness to perform CPR in these communities.

Methods and Results

We categorized each Victorian postcode as either a low or high bystander CPR region using data on adult, bystander‐witnessed, out‐of‐hospital cardiac arrests of presumed cardiac etiology (n=7175) from the Victorian Ambulance Cardiac Arrest Registry. We then surveyed adult Victorians (n=404) and compared CPR training data of the respondents from low and high bystander CPR regions. Of the 404 adults surveyed, 223 (55%) resided in regions with low bystander CPR. Compared with respondents from high bystander CPR regions, respondents residing in regions with low bystander CPR had lower rates of CPR training (62% versus 75%, P=0.009) and lower self‐ratings for their overall knowledge of CPR (76% versus 84%, P=0.04). There were no differences between the regions in their reasons for not having undergone CPR training or in their willingness to perform CPR. Rates of survival for bystander‐witnessed, out‐of‐hospital cardiac arrests were significantly lower in low bystander CPR regions (15.7% versus 17.0%, P<0.001).

Conclusions

This study found lower rates of CPR training and lower survival in regions with lower rates of bystander CPR in Victoria, Australia. Targeting these regions with CPR training programs may improve bystander CPR rates and out‐of‐hospital cardiac arrest outcomes.

Reliability of trauma management videos on YouTube and their compliance with ATLS® (9th edition) guideline

OBJECTIVE

In this study, the reliability of trauma management scenario videos (in English) on YouTube and their compliance with Advanced Trauma Life Support (ATLS^®) guidelines were investigated.

METHODS

The search was conducted on February 15, 2016 by using the terms "assessment of trauma" and ''management of trauma''. All videos that were uploaded between January 2011 and June 2016 were viewed by two experienced emergency physicians. The data regarding the date of upload, the type of the uploader, duration of the video and view counts were recorded. The videos were categorized according to the video source and scores.

RESULTS

The search results yielded 880 videos. Eight hundred and thirteen videos were excluded by the researchers. The distribution of videos by years was found to be balanced. The scores of videos uploaded by an institution were determined to be higher compared to other groups (p = 0.003).

CONCLUSION

The findings of this study display that trauma management videos on YouTube in the majority of cases are not reliable/compliant with ATLS-guidelines and can therefore not be recommended for educational purposes. These data may only be used in public education after making necessary arrangements.

Pravastatin But Not Simvastatin Improves Survival and Neurofunctional Outcome After Cardiac Arrest and Cardiopulmonary Resuscitation

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In a murine model of CA and CPR, intravenous application of hydrophilic pravastatin resulted in increased survival and neurofunctional outcome.

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In contrast, intravenous application of lipophilic simvastatin did not improve survival or neurofunction following CA/CPR.

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Pravastatin, but not simvastatin, treatment reduced post-resuscitation pulmonary edema and augmented pulmonary function.

•

In vitro, pravastatin augmented endothelial cell function, whereas simvastatin induced endothelial cell apoptosis.

•

This study supports previous requests for an intravenous formulation of hydrophilic statins for clinical use.

Cardiac arrest (CA) followed by cardiopulmonary resuscitation (CPR) is associated with high mortality and poor neurological outcome. We compared the effects of pravastatin and simvastatin on survival and neurofunction in a murine model of CA/CPR. Pravastatin, a hydrophilic statin, increased survival and neurofunction during a 28-day follow-up period. This therapy was associated with improved pulmonary function, reduced pulmonary edema, and increased endothelial cell function in vitro. In contrast, lipophilic simvastatin did not modulate survival but increased pulmonary edema and impaired endothelial cell function. Although pravastatin may display a therapeutic option for post-CA syndrome, the application of simvastatin may require re-evaluation.

We need to include bystander first aid in trauma research

Background

The chain of trauma survival is a concept that originated in the area of out-of-hospital cardiac arrest (OHCA) and was adapted to the treatment of trauma. In out-of-hospital cardiac arrest research into bystander first aid has resulted in improved outcome. Whereas, in trauma research the first link of the chain of survival is almost ignored.

Methods

In OHCA, cardiopulmonary resuscitation (CPR) from bystanders has been subject of a vast amount of research, as well as measures and programs to raise the rate of bystander CPR to cardiac arrest victims. These efforts have resulted in improved survival. The research effort has been well grounded in the research community, as demonstrated by its natural inclusion in the uniform reporting template (Utstein) for the treatment of OHCA. In trauma the bystander may contribute by providing an open airway, staunch bleedings, or prevent hypothermia. In trauma however, while the chain of survival has been adopted along with it distinct links, including bystander first aid, the consensus-based uniform reporting template for trauma (the Utstein template) does not include the bystander first aid efforts. There is extremely little research on what first aid measures bystanders provide to trauma victims, and on what impact such measures have on outcome. An important step to improve research on bystander first aid in trauma would be to include this as part of the uniform reporting template for trauma

Conclusion

The lack of research on bystander first aid makes the first link in the trauma chain of survival the weakest link. We, the trauma research community, should either improve our research and knowledge in this area, or remove the link from the chain of survival

A nationwide survey of first aid training and encounters in Norway

Background

Bystander first aid can improve survival following out-of-hospital cardiac arrest or trauma. Thus, providing first aid education to laypersons may lead to better outcomes. In this study, we aimed to establish the prevalence and distribution of first aid training in the populace, how often first aid skills are needed, and self-reported helping behaviour.

Methods

We conducted a telephone survey of 1000 respondents who were representative of the Norwegian population. Respondents were asked where and when they had first aid training, if they had ever encountered situations where first aid was necessary, and stratified by occupation. First aid included cardio-pulmonary resuscitation (CPR) and basic life support (BLS). To test theoretical first aid knowledge, respondents were subjected to two hypothetical first aid scenarios.

Results

Among the respondents, 90% had received first aid training, and 54% had undergone first aid training within the last 5 years. The workplace was the most common source of first aid training. Of the 43% who had been in a situation requiring first aid, 89% had provided first aid in that situation. There were considerable variations among different occupations in first aid training, and exposure to situations requiring first aid. Theoretical first aid knowledge was not as good as expected in light of the high share who had first aid training. In the presented scenarios 42% of respondent would initiate CPR in an unconscious patient not breathing normally, and 46% would provide an open airway to an unconscious road traffic victim. First aid training was correlated with better theoretical knowledge, but time since first aid training was not.

Conclusions

A high proportion of the Norwegian population had first aid training, and interviewees reported high willingness to provide first aid. Theoretical first aid knowledge was worse than expected. While first aid is part of national school curriculum, few have listed school as the source for their first aid training.

Electronic supplementary material

The online version of this article (doi:10.1186/s12873-017-0116-7) contains supplementary material, which is available to authorized users.

Part 3: Adult Basic Life Support and Automated External Defibrillation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This review comprises the most extensive literature search and evidence evaluation to date on the most important international BLS interventions, diagnostics, and prognostic factors for cardiac arrest victims. It reemphasizes that the critical lifesaving steps of BLS are (1) prevention, (2) immediate recognition and activation of the emergency response system, (3) early high-quality CPR, and (4) rapid defibrillation for shockable rhythms. Highlights in prevention indicate the rational and judicious deployment of search-and-rescue operations in drowning victims and the importance of education on opioid-associated emergencies. Other 2015 highlights in recognition and activation include the critical role of dispatcher recognition and dispatch-assisted chest compressions, which has been demonstrated in multiple international jurisdictions with consistent improvements in cardiac arrest survival. Similar to the 2010 ILCOR BLS treatment recommendations, the importance of high quality was reemphasized across all measures of CPR quality: rate, depth, recoil, and minimal chest compression pauses, with a universal understanding that we all should be providing chest compressions to all victims of cardiac arrest. This review continued to focus on the interface of BLS sequencing and ensuring high-quality CPR with other important BLS interventions, such as ventilation and defibrillation. In addition, this consensus statement highlights the importance of EMS systems, which employ bundles of care focusing on providing high-quality chest compressions while extricating the patient from the scene to the next level of care. Highlights in defibrillation indicate the global importance of increasing the number of sites with public-access defibrillation programs. Whereas the 2010 ILCOR Consensus on Science provided important direction for the “what” in resuscitation (ie, what to do), the 2015 consensus has begun with the GRADE methodology to provide direction for the quality of resuscitation. We hope that resuscitation councils and other stakeholders will be able to translate this body of knowledge of international consensus statements to build their own effective resuscitation guidelines.

Regions of High Out-Of-Hospital Cardiac Arrest Incidence and Low Bystander CPR Rates in Victoria, Australia

Background

Out-of-hospital cardiac arrest (OHCA) remains a major public health issue and research has shown that large regional variation in outcomes exists. Of the interventions associated with survival, the provision of bystander CPR is one of the most important modifiable factors. The aim of this study is to identify census areas with high incidence of OHCA and low rates of bystander CPR in Victoria, Australia

Methods

We conducted an observational study using prospectively collected population-based OHCA data from the state of Victoria in Australia. Using ArcGIS (ArcMap 10.0), we linked the location of the arrest using the dispatch coordinates (longitude and latitude) to Victorian Local Government Areas (LGAs). We used Bayesian hierarchical models with random effects on each LGA to provide shrunken estimates of the rates of bystander CPR and the incidence rates.

Results

Over the study period there were 31,019 adult OHCA attended, of which 21,436 (69.1%) cases were of presumed cardiac etiology. Significant variation in the incidence of OHCA among LGAs was observed. There was a 3 fold difference in the incidence rate between the lowest and highest LGAs, ranging from 38.5 to 115.1 cases per 100,000 person-years. The overall rate of bystander CPR for bystander witnessed OHCAs was 62.4%, with the rate increasing from 56.4% in 2008–2010 to 68.6% in 2010–2013. There was a 25.1% absolute difference in bystander CPR rates between the highest and lowest LGAs.

Conclusion

Significant regional variation in OHCA incidence and bystander CPR rates exists throughout Victoria. Regions with high incidence and low bystander CPR participation can be identified and would make suitable targets for interventions to improve CPR participation rates.

Bystander first aid in trauma - prevalence and quality: a prospective observational study

Background

Bystander first aid and basic life support can likely improve victim survival in trauma. In contrast to bystander first aid and out‐of‐hospital cardiac arrest, little is known about the role of bystanders in trauma response. Our aim was to determine how frequently first aid is given to trauma victims by bystanders, the quality of this aid, the professional background of first‐aid providers, and whether previous first‐aid training affects aid quality.

Methods

We conducted a prospective 18‐month study in two mixed urban–rural Norwegian counties. The personnel on the first ambulance responding to trauma calls assessed and documented first aid performed by bystanders using a standard form.

Results

A total of 330 trauma calls were included, with bystanders present in 97% of cases. Securing an open airway was correctly performed for 76% of the 43 patients in need of this first‐aid measure. Bleeding control was provided correctly for 81% of 63 patients for whom this measure was indicated, and prevention of hypothermia for 62% of 204 patients. Among the first‐aid providers studied, 35% had some training in first aid. Bystanders with documented first‐aid training gave better first aid than those where first‐aid training status was unknown.

Conclusions

A majority of the trauma patients studied received correct pre‐hospital first aid, but still there is need for considerable improvement, particularly hypothermia prevention. Previous first‐aid training seems to improve the quality of first aid provided. The effect on patient survival needs to be investigated.

Using a cardiac arrest registry to measure the quality of emergency medical service care: decade of findings from the Victorian Ambulance Cardiac Arrest Registry

BACKGROUND

Although the value of clinical registries has been well recognized in developed countries, their use for measuring the quality of emergency medical service care remains relatively unknown. We report the methodology and findings of a statewide emergency medical service surveillance initiative, which is used to measure the quality of systems of care for patients with out-of-hospital cardiac arrest.

METHODS AND RESULTS

Between July 1, 2002, and June 30, 2012, data for adult out-of-hospital cardiac arrest cases of presumed cardiac cause occurring in the Australian Southeastern state of Victoria were extracted from the Victorian Ambulance Cardiac Arrest Registry. Regional and temporal trends in bystander cardiopulmonary resuscitation, event survival, and survival to hospital discharge were analyzed using logistic regression and multilevel modeling. A total of 32,097 out-of-hospital cardiac arrest cases were identified, of whom 14,083 (43.9%) received treatment by the emergency medical service. The risk-adjusted odds of receiving bystander cardiopulmonary resuscitation (odds ratio [OR], 2.96; 95% confidence interval, 2.62-3.33), event survival (OR, 1.55; 95% confidence interval, 1.30-1.85), and survival to hospital discharge (OR, 2.81; 95% confidence interval, 2.07-3.82) were significantly improved by 2011 to 2012 compared with baseline. Significant variation in rates of bystander cardiopulmonary resuscitation and survival were observed across regions, with arrests in rural regions less likely to survive to hospital discharge. The median OR for interhospital variability in survival to hospital discharge outcome was 70% (median OR, 1.70).

CONCLUSIONS

Between 2002 and 2012, there have been significant improvements in bystander cardiopulmonary resuscitation and survival outcome for out-of-hospital cardiac arrest patients in Victoria, Australia. However, regional survival disparities and interhospital variability in outcomes pose significant challenges for future improvements in care.

Quality of life and functional outcomes 12 months after out-of-hospital cardiac arrest

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a significant global health problem. There has been considerable investment in improving the emergency medical response to OHCA, with associated improvements in survival. However, concern remains that survivors have a poor quality of life. This study describes the quality of life of OHCA survivors at 1-year postarrest in Victoria, Australia.

METHODS AND RESULTS

Adult OHCA patients who arrested between 2010 and 2012 were identified from the Victorian Ambulance Cardiac Arrest Registry. Paramedics attended 15 113 OHCA patients of which 46.3% received an attempted resuscitation. Nine hundred and twenty-seven (13.2%) survived to hospital discharge of which 76 (8.2%) died within 12 months. Interviews were conducted with 697 (80.7%) patients or proxies, who were followed-up via telephone interview, including the Glasgow Outcome Scale-Extended, the 12-item short form health survey, and the EuroQol. The majority (55.6%) of respondents had a good recovery via the Glasgow Outcome Scale-Extended≥7 (41.1% if patients who died postdischarge were included and nonrespondents were assumed to have poor recovery). The mean EuroQol index score for respondents was 0.82 (standard deviation, 0.19), which compared favorably with an adjusted population norm of 0.81 (standard deviation, 0.34). The mean 12-item short form Mental Component Summary score for patients was 53.0 (standard deviation, 10.2), whereas the mean Physical Component Summary score was 46.1 (standard deviation, 11.2).

CONCLUSIONS

This is the largest published study assessing the quality of life of OHCA survivors. It provides good evidence that many survivors have an acceptable quality of life 12 months postarrest, particularly in comparison with population norms.

Effects of repetitive or intensified instructions in telephone assisted, bystander cardiopulmonary resuscitation: an investigator-blinded, 4-armed, randomized, factorial simulation trial

BACKGROUND

Compression depth is frequently suboptimal in cardiopulmonary resuscitation (CPR). We investigated effects of intensified wording and/or repetitive target depth instructions on compression depth in telephone-assisted, protocol driven, bystander CPR on a simulation manikin.

METHODS

Thirty-two volunteers performed 10 min of compression only-CPR in a prospective, investigator-blinded, 4-armed, factorial setting. Participants were randomized either to standard wording ("push down firmly 5 cm"), intensified wording ("it is very important to push down 5 cm every time") or standard or intensified wording repeated every 20s. Three dispatchers were randomized to give these instructions. Primary outcome was relative compression depth (absolute compression depth minus leaning depth). Secondary outcomes were absolute distance, hands-off times as well as BORG-scale and nine-hole peg test (NHPT), pulse rate and blood pressure to reflect physical exertion. We applied a random effects linear regression model.

RESULTS

Relative compression depth was 35 ± 10 mm (standard) versus 31 ± 11 mm (intensified wording) versus 25 ± 8 mm (repeated standard) and 31 ± 14 mm (repeated intensified wording). Adjusted for design, body mass index and female sex, intensified wording and repetition led to decreased compression depth of 13 (95%CI -25 to -1) mm (p=0.04) and 9 (95%CI -21 to 3) mm (p=0.13), respectively. Secondary outcomes regarding intensified wording showed significant differences for absolute distance (43 ± 2 versus 20 (95%CI 3-37) mm; p=0.01) and hands-off times (60 ± 40 versus 157 (95%CI 63-251) s; p=0.04).

CONCLUSION

In protocol driven, telephone-assisted, bystander CPR, intensified wording and/or repetitive target depth instruction will not improve compression depth compared to the standard instruction.

Out-of-hospital cardiac arrest in Cork, Ireland

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) in Ireland accounts for approximately 5000 deaths annually. Little published evidence exists on survival from OHCA in this country to date. We aimed to characterise and describe 'presumed cardiac' OHCA in Cork City and County attended by the Ambulance Service.

METHODS

Dispatch records, ambulance patient records and hospital records for a 1-year period were examined for patient demographics, OHCA characteristics, interventions and patient outcomes.

RESULTS

There were 231 'presumed cardiac' OHCAs attended over the study period; 130 (56%) were in urban locations and 101 (44%) in rural. OHCAs were lay-witnessed in 20% (n=46), and 22% (n=50) received bystander CPR. Shockable rhythm was present in 36 cases (16%) on initial assessment, and there was no difference in presence of shockable rhythm between urban and rural OHCAs (18% vs 13%, p=0.31). Resuscitation was attempted in 176 cases (77.5%), of whom 27 (15%) achieved return of spontaneous circulation and 13 (7.4%) survived to leave hospital. Survival when the initial rhythm was shockable was 16.7% (6 of 36 patients). Despite longer response times for rural compared with urban OHCAs (median (IQR) 16.5 (11.0-23.5) vs 9 (7-12) min, p<0.001), survival to leave hospital alive where resuscitation was attempted was similar (7.4% vs 7.4%, p=0.99, respectively).

CONCLUSION

A survival rate of 16.7% in shockable rhythms indicates scope for improvement which would influence the overall survival rate which was found to be 7.4%. Real-time feedback of performance and quality of the continuum of patient care through a clinical-quality cardiac arrest registry would monitor and incentivise such initiatives.