Impact of telephone dispatcher assistance on the outcomes of pediatric out-of-hospital cardiac arrest*:

The barriers and facilitators to initiation of telephone-assisted bystander cardiopulmonary resuscitation for patients experiencing out-of-hospital cardiac arrest in a private emergency dispatch centre in South Africa

Background

The incidence of cardiovascular diseases, and with it out-of-hospital cardiac arrest (OHCA), is on the increase in low- to middle-income countries (LMICs), like South Africa. Interventions such as mass public cardiopulmonary resuscitation (CPR) training campaigns and public access defibrillators are expensive and out of reach for many LMICs. Telephone-assisted CPR (tCPR) is a cost-effective, scalable alternative. This study explored the barriers and facilitators to tCPR uptake in OHCA in a private South African emergency dispatch centre.

Methods

This qualitative study applied inductive dominant content analysis to emergency call recordings of OHCA cases into a private emergency dispatch centre. Calls were analysed to the latent level to identify barriers and facilitators. Cases were sampled randomly, until data saturation.

Results

Saturation occurred after the analysis of 25 recordings. A further three recordings were analysed to confirm saturation of the facilitators; yielding a final sample size of 28 calls. Overall, t-CPR was offered in 23 (82.1%) cases, but only initiated in 8 (34.8%) of these calls. Five barriers ("Poor Communication"; "Lack of Support"; "Caller Hesitance or Uncertainty;" "Emotionality"; and "Practical Barriers") and three facilitators ("Caller Willingness"; "Support" and "CPR in Progress") were extracted.

Conclusion

Numerous barriers limit the initiation of tCPR in the South African private sector EMS. It is crucial to address these barriers and leverage the facilitators in order to improve tCPR uptake. This study highlights the importance of using specific language techniques and developing tailored tCPR algorithms to overcome these barriers, which is underpinned by standardised training of call-takers.

Pediatric Out-of-Hospital Cardiac Arrest: The Role of the Telecommunicator in Recognition of Cardiac Arrest and Delivery of Bystander Cardiopulmonary Resuscitation

BACKGROUND

Telecommunicator CPR (T-CPR), whereby emergency dispatch facilitates cardiac arrest recognition and coaches CPR over the telephone, is an important strategy to increase early recognition and bystander CPR in adult out-of-hospital cardiac arrest (OHCA). Little is known about this treatment strategy in the pediatric population. We investigated the role of T-CPR and related performance among pediatric OHCA.

METHODS AND RESULTS

This study was a retrospective cohort investigation of OHCA among individuals <18 years in King County, Washington, from April 1, 2013, to December 31, 2019. We reviewed the 911 audio recordings to determine if and how bystander CPR was delivered (unassisted or T-CPR), key time intervals in recognition of arrest, and key components of T-CPR delivery. Of the 185 eligible pediatric OHCAs, 23% (n=43) had bystander CPR initiated unassisted, 59% (n=109) required T-CPR, and 18% (n=33) did not receive CPR before emergency medical services arrival. Among all cases, cardiac arrest was recognized by the telecommunicator in 89% (n=165). Among those receiving T-CPR, the median (interquartile range) interval from start of call to OHCA recognition was 59 seconds (38-87) and first CPR intervention was 115 seconds (94-162). When stratified by age (≤8 versus >8), the older age group was less likely to receive CPR before emergency medical services arrival (88% versus 69%, P=0.002). For those receiving T-CPR, bystanders spent a median of 207 seconds (133-270) performing CPR. The median compression rate was 93 per minute (82-107) among those receiving T-CPR.

CONCLUSIONS

T-CPR is an important strategy to increase early recognition and early CPR among pediatric OHCA.

Comparison of paediatric basic life support guidelines endorsed by member councils of Resuscitation Council of Asia

Background

Paediatric cardiac arrest outcomes, especially for infants, remain poor. Due to different training, resource differences, and historical reasons, paediatric cardiac arrest algorithms for various Asia countries vary. While there has been a common basic life support algorithm for adults by the Resuscitation Council of Asia (RCA), there is no common RCA algorithm for paediatric life support.We aimed to review published paediatric life support guidelines from different Asian resuscitation councils.

Methods

Pubmed and Google Scholar search were performed for published paediatric basic and advanced life support guidelines from January 2015 to June 2023. Paediatric representatives from the Resuscitation Council of Asia were sought and contacted to provide input from September 2022 till June 2023.

Results

While most of the components of published paediatric life support algorithms of Asian countries are similar, there are notable variations in terms of age criteria for recommended use of adult basic life support algorithms in the paediatric population less than 18 years old, recommended paediatric chest compression depth targets, ventilation rates post-advanced airway intra-arrest, and first defibrillation dose for shockable rhythms in paediatric cardiac arrest.

Conclusion

This was an overview and mapping of published Asian paediatric resuscitation algorithms. It highlights similarities across paediatric life support guidelines in Asian countries. There were some differences in components of paediatric life support which highlight important knowledge gaps in paediatric resuscitation science. The minor differences in the paediatric life support guidelines endorsed by the member councils may provide a framework for prioritising resuscitation research and highlight knowledge gaps in paediatric resuscitation.

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.

Can Video Assistance Improve the Quality of Pediatric Dispatcher-Assisted Cardiopulmonary Resuscitation?

OBJECTIVES

This study aimed to evaluate the impact of adding video conferencing to dispatcher-assisted telephone cardiopulmonary resuscitation (CPR) on pediatric bystander CPR quality.

METHODS

We conducted a prospective, randomized manikin study among volunteers with no CPR training and among bachelor nurses. Volunteers randomly received either video or audio assistance in a 6-minute pediatric cardiac arrest scenario. The main outcome measures were the results of the Cardiff Test to assess compression and ventilation performance.

RESULTS

Of 255 candidates assessed for eligibility, 120 subjects were randomly assigned to 1 of the 4 following groups: untrained telephone-guided (U-T; n = 30) or video-guided (U-V; n = 30) groups and trained telephone-guided (T-T; n = 30) or video-guided (T-V; n = 30) groups. Cardiac arrest was appropriately identified in 86.7% of the U-T group and in 100% in the other groups (P = 0.0061). Hand positioning was adequate in 76.7% of T-T, 80% of T-V, and 60% of U-V, as compared with 23.4% of the U-T group (P = 0.0001). Fewer volunteers managed to deliver 2 rescue breaths/cycle (P = 0.0001) in the U-T (16.7%) compared with the U-V (43.3%), the T-T (56.7%), and the T-V groups (60%).Subjects in the video groups had a lower fraction of minute to ventilate as compared with the telephone groups (P = 0.0005).

CONCLUSIONS

In dispatcher-instructed children CPR simulation, using video assistance improves cardiac arrest recognition and CPR quality with more appropriate chest compression technique and ventilation delivering. The long interruptions in chest compression combined with the mixed success rate to deliver proper ventilation raise question about ventilation quality and its effectiveness.

European Resuscitation Council Guidelines 2021: Systems saving lives

The European Resuscitation Council (ERC) has produced these Systems Saving Lives guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include chain of survival, measuring performance of resuscitation, social media and smartphones apps for engaging community, European Restart a Heart Day, World Restart a Heart, KIDS SAVE LIVES campaign, lower-resource setting, European Resuscitation Academy and Global Resuscitation Alliance, early warning scores, rapid response systems, and medical emergency team, cardiac arrest centres and role of dispatcher.

Patient outcomes of school-age, out-of-hospital cardiac arrest in Japan: A nationwide study of schoolchildren as witnesses

Aim

Using the data from the All‐Japan Utstein Registry, this study evaluates the neurologically favourable patient outcomes and associated factors of out‐of‐hospital cardiac arrest (OHCA) with Japanese schoolchildren as witnesses.

Methods

We analysed 1,068 school‐age children (6–18 years old) who underwent OHCA from 2011 to 2016. Among the 1,068 cases, 179 were witnessed by schoolchildren and 889 were witnessed by other bystanders. Propensity score‐matched and logistic regression analyses were used to evaluate the outcomes and associated factors.

Results

The crude neurologically favourable outcome in the schoolchildren‐witnessed group was considerably higher than that in the other‐bystander‐witnessed group (19.6% versus 12.3%; P < 0.010). However, the difference was not significant in the propensity score‐matched analysis (19.6% versus 21.8%; P = 0.602). The multivariable logistic regression analyses of school‐age OHCA with schoolchildren as witnesses demonstrated that bystander cardiopulmonary resuscitation (CPR) provision (odds ratio [OR] 4.12, 95% confidence interval [CI] 1.44–11.75), shockable initial rhythm (OR 3.39, 95% CI 1.43–8.04), and defibrillation (OR 4.58, 95% CI 1.65–12.71) provided by any bystander were positively associated with favourable outcomes. By contrast, dispatcher‐assisted CPR provision (OR 0.28, 95% CI 0.11–0.70), exogenous cause (OR 0.16, 95% CI 0.03–0.86), adrenaline administration (0.25; 95% CI 0.07–0.92), and prolonged response time (OR 0.86; 95% CI 0.75–0.98) were negatively associated with favourable outcomes.

Conclusions

Patient outcomes did not differ significantly between schoolchildren‐ and other‐bystander‐witnessed cases of school‐age OHCA. Although schoolchildren as witnesses might not be inferior to other bystanders in school‐age OHCA, further studies are needed to examine the effect of bystander CPR by schoolchildren and basic life support education in schools.

Part 7: Systems of Care: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Survival after cardiac arrest requires an integrated system of people, training, equipment, and organizations working together to achieve a common goal. Part 7 of the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care focuses on systems of care, with an emphasis on elements that are relevant to a broad range of resuscitation situations. Previous systems of care guidelines have identified a Chain of Survival, beginning with prevention and early identification of cardiac arrest and proceeding through resuscitation to post-cardiac arrest care. This concept is reinforced by the addition of recovery as an important stage in cardiac arrest survival. Debriefing and other quality improvement strategies were previously mentioned and are now emphasized. Specific to out-of-hospital cardiac arrest, this Part contains recommendations about community initiatives to promote cardiac arrest recognition, cardiopulmonary resuscitation, public access defibrillation, mobile phone technologies to summon first responders, and an enhanced role for emergency telecommunicators. Germane to in-hospital cardiac arrest are recommendations about the recognition and stabilization of hospital patients at risk for developing cardiac arrest. This Part also includes recommendations about clinical debriefing, transport to specialized cardiac arrest centers, organ donation, and performance measurement across the continuum of resuscitation situations.

Telephone CPR: Current Status, Challenges, and Future Perspectives

With each successive update of the cardiopulmonary resuscitation (CPR) guidelines, the role of dispatchers in sudden cardiac arrest (CA) has grown. Dispatchers instruct callers in how to perform CPR until the arrival of emergency medical service (EMS) professionals. This is widely known as telephone CPR (TCPR) or dispatch-assisted CPR (DACPR). Studies have shown the efficacy of TCPR in increasing the survival rate of sudden CA. The TCPR process, however, is challenging and needs to be constantly evaluated and refined in order to improve the survival rate of sudden CA victims throughout the world. In this review article, the current status, challenges, and future perspectives of TCPR are discussed with a view to providing a research foundation from which to launch further studies into the effective role of dispatchers in sudden CA.

Epidemiology of pediatric cardiopulmonary resuscitation

OBJECTIVE

To analyze the main epidemiological aspects of prehospital and hospital pediatric cardiopulmonary resuscitation and the impact of scientific evidence on survival.

SOURCE OF DATA

This was a narrative review of the literature published at PubMed/MEDLINE until January 2019 including original and review articles, systematic reviews, meta-analyses, annals of congresses, and manual search of selected articles.

SYNTHESIS OF DATA

The prehospital and hospital settings have different characteristics and prognoses. Pediatric prehospital cardiopulmonary arrest has a three-fold lower survival rate than cardiopulmonary arrest in the hospital setting, occurring mostly at home and in children under 1year. Higher survival appears to be associated with age progression, shockable rhythm, emergency medical care, use of automatic external defibrillator, high-quality early life support, telephone dispatcher-assisted cardiopulmonary resuscitation, and is strongly associated with witnessed cardiopulmonary arrest. In the hospital setting, a higher incidence was observed in children under 1year of age, and mortality increased with age. Higher survival was observed with shorter cardiopulmonary resuscitation duration, occurrence on weekdays and during daytime, initial shockable rhythm, and previous monitoring. Despite the poor prognosis of pediatric cardiopulmonary resuscitation, an increase in survival has been observed in recent years, with good neurological prognosis in the hospital setting.

CONCLUSIONS

A great progress in the science of pediatric cardiopulmonary resuscitation has been observed, especially in developed countries. The recognition of the epidemiological aspects that influence cardiopulmonary resuscitation survival may direct efforts towards more effective actions; thus, studies in emerging and less favored countries remains a priority regarding the knowledge of local factors.

Impact of Dispatcher-Assisted Bystander Cardiopulmonary Resuscitation with Out-of-Hospital Cardiac Arrest: A Systemic Review and Meta-Analysis

OBJECTIVE

This systemic review and meta-analysis was conducted to explore the impact of dispatcher-assisted bystander cardiopulmonary resuscitation (DA-BCPR) on bystander cardiopulmonary resuscitation (BCPR) probability, survival, and neurological outcomes with out-of-hospital cardiac arrest (OHCA).

METHODS

Electronically searching of PubMed, Embase, and Cochrane Library, along with manual retrieval, were done for clinical trials about the impact of DA-BCPR which were published from the date of inception to December 2018. The literature was screened according to inclusion and exclusion criteria, the baseline information, and interested outcomes were extracted. Two reviewers assessed the methodological quality of the included studies. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated by STATA version 13.1.

RESULTS

In 13 studies, 235,550 patients were enrolled. Compared with no dispatcher instruction, DA-BCPR tended to be effective in improving BCPR rate (I2 = 98.2%; OR = 5.84; 95% CI, 4.58-7.46; P <.01), return of spontaneous circulation (ROSC) before admission (I2 = 36.0%; OR = 1.17; 95% CI, 1.06-1.29; P <.01), discharge or 30-day survival rate (I2 = 47.7%; OR = 1.25; 95% CI, 1.06-1.46; P <.01), and good neurological outcome (I2 = 30.9%; OR = 1.24; 95% CI, 1.04-1.48; P = .01). However, no significant difference in hospital admission was found (I2 = 29.0%; OR = 1.09; 95% CI, 0.91-1.30; P = .36).

CONCLUSION

This review shows DA-BPCR plays a positive role for OHCA as a critical section in the life chain. It is effective in improving the probability of BCPR, survival, ROSC before admission, and neurological outcome.

2019 American Heart Association Focused Update on Pediatric Basic Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

This 2019 focused update to the American Heart Association pediatric basic life support guidelines follows the 2019 systematic review of the effects of dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) on survival of infants and children with out-of-hospital cardiac arrest. This systematic review and the primary studies identified were analyzed by the Pediatric Task Force of the International Liaison Committee on Resuscitation. It aligns with the International Liaison Committee on Resuscitation's continuous evidence review process, with updates published when the International Liaison Committee on Resuscitation completes a literature review based on new published evidence. This update summarizes the available pediatric evidence supporting DA-CPR and provides treatment recommendations for DA-CPR for pediatric out-of-hospital cardiac arrest. Four new pediatric studies were reviewed. A systematic review of this data identified the association of a significant improvement in the rates of bystander CPR and in survival 1 month after cardiac arrest with DA-CPR. The writing group recommends that emergency medical dispatch centers offer DA-CPR for presumed pediatric cardiac arrest, especially when no bystander CPR is in progress. No recommendation could be made for or against DA-CPR instructions when bystander CPR is already in progress.

2019 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

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the 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. The task forces also listed priority knowledge gaps for further research.

2019 American Heart Association Focused Update on Systems of Care: Dispatcher-Assisted Cardiopulmonary Resuscitation and Cardiac Arrest Centers: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Survival after out-of-hospital cardiac arrest requires an integrated system of care (chain of survival) between the community elements responding to an event and the healthcare professionals who continue to care for and transport the patient for appropriate interventions. As a result of the dynamic nature of the prehospital setting, coordination and communication can be challenging, and identification of methods to optimize care is essential. This 2019 focused update to the American Heart Association systems of care guidelines summarizes the most recent published evidence for and recommendations on the use of dispatcher-assisted cardiopulmonary resuscitation and cardiac arrest centers. This article includes the revised recommendations that emergency dispatch centers should offer and instruct bystanders in cardiopulmonary resuscitation during out-of-hospital cardiac arrest and that a regionalized approach to post-cardiac arrest care may be reasonable when comprehensive postarrest care is not available at local facilities.

Effectiveness of dispatcher instructions-dependent or independent bystander cardiopulmonary resuscitation on neurological survival among patients with out-of-hospital cardiac arrest

BACKGROUND

We evaluated the association between survival and bystandercardiopulmonary resuscitation (CPR) with or without dispatcher instructions (DI) considering the time from emergency call receipt by the dispatch center to emergency medical services (EMS) personnel's contact with the patient (i.e. time to EMS arrival).

METHODS

This prospective study conducted in Osaka City, Japan, from 2009 to 2015 included patients with medical cause-related out-of-hospital cardiac arrest who were ≥18 years old. The primary outcome was one-month favorable neurological survival. Using multiple logistic regression models, the adjusted odds ratios (AOR) of independent and DI-dependent CPR for the primary outcome were compared with no CPR. Adjustments were made for patients' age, sex, activities of daily living before the cardiac arrest, year of cardiac arrest, location, presence or absence of witnesses, etiology of cardiac arrest, and the time from EMS contact with the patient to patient's arrival at the hospital. The effective estimated "time to EMS arrival" was also calculated.

RESULTS

For analyses 10,925 individuals were eligible. Independent CPR had a significantly higher one-month favorable neurological survival than no CPR whereas there was no significant difference between DI-dependent CPR and no CPR (AOR, 1.90 [1.47-2.46] and 1.16 [0.91-1.47], respectively). The estimated "time to EMS arrival" for a one-month favorable neurological survival after independent CPR was ≤13min.

CONCLUSIONS

Bystander CPR that did not need DI was associated with significantly higher one-month favorable neurological survival than no CPR, with an effective estimated "time to EMS arrival" of ≤13min.

Dispatcher-Assisted Cardiopulmonary Resuscitation Program and Outcomes After Pediatric Out-of-Hospital Cardiac Arrest

OBJECTIVES

A dispatcher-assisted bystander cardiopulmonary resuscitation (DA-BCPR) is expected to influence the outcomes of pediatric out-of-hospital cardiac arrest (OHCA). Our objective was to measure the effect size of a DA-BCPR on survival outcomes according to location of the event.

METHODS

All emergency medical service treated OHCA patients younger than 19 years in Korea from January 2012 through December 2013 were analyzed. Patients with OHCA witnessed by emergency medical service providers and those with missing outcome information were excluded. Patients were categorized into the following categories: No-BCPR, BCPR without dispatcher assistance (BCPR-NDA), and BCPR-DA. The primary outcome was survival to hospital discharge. Multivariable logistic regression analysis was performed to calculate the adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for outcomes by exposure group (reference, No-BCPR group) with and without an interaction term between exposure and location of arrest.

RESULTS

A total of 1013 eligible patients were analyzed. Among these patients, 16.6% received BCPR-NDA, 23.2% received BCPR-DA, and 60.2% received no BCPR. After adjusting for potential confounders, compared with N0-BCPR group, AORs for survival were 1.79 (95% CI, 1.03-3.12) in BCPR group, 1.71 (95% CI, 0.85-3.46) in BCPR-NDA group, and 1.39 (95% CI, 0.72-2.69) in BCPR-DA group. The AORs for survival of BCPR-NDA and BCPR-DA in public location were 3.30 (95% CI, 1.12-9.72) and 2.95 (95% CI, 1.00-8.67), whereas BCPR-NDA and BCPR-DA in private locations were 1.62 (95% CI, 0.68-3.88) and 1.15 (95% CI, 0.53-2.51).

CONCLUSION

The DA-CPR was associated with better outcomes in pediatric OHCA patients whose arrest occurred in public locations, but no improvement in outcomes was identified in patients whose arrest occurred at private locations.

A systematic review and meta-analysis of the effect of dispatcher-assisted CPR on outcomes from sudden cardiac arrest in adults and children

BACKGROUND

Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) has been reported in individual studies to significantly increase the rate of bystander CPR and survival from cardiac arrest.

METHODS

We undertook a systematic review and meta-analysis to evaluate the impact of DA-CPR programs on key clinical outcomes following out-of-hospital cardiac arrest. We searched the PubMED, EMBASE, CINAHL, ERIC and Cochrane Central Register of Controlled Trials databases from inception until July 2018. Eligible studies compared systems with and without dispatcher-assisted CPR programs. The results of included studies were classified into 3 categories for the purposes of more accurate analysis: comparison of outcomes in systems with DA-CPR programs, case-based comparison of DA-CPR to bystander CPR, and case-based comparisons of DA-CPR to no CPR before EMS arrival. The GRADE system was used to assess certainty of evidence at an outcome level. We used random-effects models to produce summary effect sizes across all outcomes.

RESULTS

Of 5531 citations screened, 33 studies were eligible for inclusion. All included studies were observational. Evidence certainty across all outcomes was assessed as low or very low. In system-level and patient-level comparisons, the provision of DA-CPR compared with no DA-CPR was consistently associated with improved outcome across all analyses. Comparison of DA-CPR to bystander CPR produced conflicting results. Findings were consistent across sensitivity analyses and the pediatric sub-group.

CONCLUSION

These results support the recommendation that dispatchers provide CPR instructions to callers for adults and children with suspected OHCA. Review registration: PROSPERO- CRD42018091427.

Real-Time Chest Compression Quality Measurements by Smartphone Camera

Out-of-hospital cardiac arrest (OHCA) is recognized as a global mortality challenge, and digital strategies could contribute to increase the chance of survival. In this paper, we investigate if cardiopulmonary resuscitation (CPR) quality measurement using smartphone video analysis in real-time is feasible for a range of conditions. With the use of a web-connected smartphone application which utilizes the smartphone camera, we detect inactivity and chest compressions and measure chest compression rate with real-time feedback to both the caller who performs chest compressions and over the web to the dispatcher who coaches the caller on chest compressions. The application estimates compression rate with 0.5 s update interval, time to first stable compression rate (TFSCR), active compression time (TC), hands-off time (TWC), average compression rate (ACR), and total number of compressions (NC). Four experiments were performed to test the accuracy of the calculated chest compression rate under different conditions, and a fifth experiment was done to test the accuracy of the CPR summary parameters TFSCR, TC, TWC, ACR, and NC. Average compression rate detection error was 2.7 compressions per minute (±5.0 cpm), the calculated chest compression rate was within ±10 cpm in 98% (±5.5) of the time, and the average error of the summary CPR parameters was 4.5% (±3.6). The results show that real-time chest compression quality measurement by smartphone camera in simulated cardiac arrest is feasible under the conditions tested.

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.

Dispatcher-Assisted Telephone Cardiopulmonary Resuscitation Using a French-Language Compression-Ventilation Pediatric Protocol

OBJECTIVE

Out-of-hospital cardiac arrest (OHCA) in pediatrics is a devastating event associated with poor survival rates. Although telephone dispatcher-assisted cardiopulmonary resuscitation (CPR; T-CPR) instructions improve the frequency and quality of bystander CPR for OHCA in adults, this support remains undeveloped in children. Our objective was to assess the effectiveness of a pediatric T-CPR protocol in untrained and trained bystanders. Secondarily, we sought to determine the feasibility and the effectiveness of ventilation in such a protocol.

METHODS

Eligible adults with no CPR experience were recruited in a movie theater in Liege, as well as bachelor nursing students in Liege. All volunteers were randomly assigned either to T-CPR or to no-T-CPR using randomization. The volunteers were exposed to a pediatric manikin model cardiac arrest. On the basis of Cardiff evaluation test, data were collected to evaluate CPR performance.

RESULTS

A total of 115 volunteers were assigned to 4 groups: untrained nonguided group (n = 27), untrained guided group (n = 32), trained nonguided group (n = 26), and trained guided group (n = 30). We found an improvement in CPR performance in the guided groups. Most volunteers (81.2%) in untrained guided group and 83.3% in the trained guided group were able to give 2 ventilations after each compressions cycle.

CONCLUSIONS

In a pediatric manikin model of OHCA, T-CPR instructions including mouth-to-mouth ventilations and chest compressions produced a significant increase in resuscitation performance not only among previously untrained but also among trained volunteers.

Effectiveness of dispatcher training in increasing bystander chest compression for out-of-hospital cardiac arrest patients in Japan

Aim

The Japanese government has developed a standardized training program for emergency call dispatchers to improve their skills in providing oral guidance on chest compression to bystanders who have witnessed out‐of‐hospital cardiac arrests (OHCAs). This study evaluated the effects of such a training program for emergency call dispatchers in Japan.

Methods

The analysis included all consecutive non‐traumatic OHCA patients transported to hospital by eight emergency medical services, where the program was implemented as a pilot project. We compared the provision of oral guidance and the incidence of chest compression applications by bystanders in the 1‐month period before and after the program. Data collection was undertaken from October 2014 to March 2015.

Results

The 532 non‐traumatic OHCA cases were used for analysis: these included 249 cases before and 283 after the guidance intervention. Most patients were over 75 years old and were men. After the program, provision of oral guidance to callers slightly increased from 63% of cases to 69% (P = 0.13) and implementation of chest compression on patients by bystanders significantly increased from 40% to 52% (P = 0.01). Appropriate chest compression also increased from 34% to 47% (P = 0.01). In analysis stratified by the provision of oral guidance, increased chest compressions were observed only under oral guidance.

Conclusions

We found increased provision of oral guidance by dispatchers and increased appropriate chest compressions by bystanders after the training program for dispatchers had been rolled out. Long‐term observation and further data analysis, including patient outcomes, are needed.

Randomised clinical simulation designed to evaluate the effect of telemedicine using Google Glass on cardiopulmonary resuscitation (CPR)

AIM

Through a clinical simulation, this study aims to assess the effect of telematics support through Google Glass (GG) from an expert physician on performance of cardiopulmonary resuscitation (CPR) performed by a group of nurses, as compared with a control group of nurses receiving no assistance.

METHODS

This was a randomised study carried out at the Catholic University of Murcia (November 2014-February 2015). Nursing professionals from the Emergency Medical Services in Murcia (Spain) were asked to perform in a clinical simulation of cardiac arrest. Half of the nurses were randomly chosen to receive coaching from physicians through GG, while the other half did not receive any coaching (controls). The main outcome of the study expected was successful defibrillation, which restores sinus rhythm.

RESULTS

Thirty-six nurses were enrolled in each study group. Statistically significant differences were found in the percentages of successful defibrillation (100% GG vs 78% control; p=0005) and CPR completion times: 213.91 s for GG and 250.31 s for control (average difference=36.39 s (95% CI 12.03 to 60.75), p=0.004).

CONCLUSIONS

Telematics support by an expert through GG improves success rates and completion times while performing CPR in simulated clinical situations for nurses in simulated scenarios.

Telephone cardiopulmonary resuscitation is independently associated with improved survival and improved functional outcome after out-of-hospital cardiac arrest

AIM OF STUDY

This study aims to quantify the relative impact of Dispatcher-Initiated Telephone cardiopulmonary resuscitation (TCPR) on survival and survival with favorable functional outcome after out-of-hospital cardiac arrest (OHCA) in a population of patients served by multiple emergency dispatch centers and more than 130 emergency medical services (EMS) agencies.

METHODS

We conducted a retrospective, observational study of EMS-treated adult (≥18 years) patients with OHCA of presumed cardiac origin in Arizona, between January 1, 2011, and December 31, 2014. We compared survival and functional outcome among three distinct groups of OHCA patients: those who received no CPR before EMS arrival (no CPR group); those who received BCPR before EMS arrival and prior to or without telephone CPR instructions (BCPR group); and those who received TCPR (TCPR group).

RESULTS

In this study, 2310 of 4391 patients met the study criteria (median age, 62 years; IQR 50, 74; 1540 male). 32.8% received no CPR, 23.8% received Bystander-Initiated CPR and 43.4% received TCPR. Overall survival was 11.5%. Using no CPR as the reference group, the multivariate adjusted odds ratio for survival at hospital discharge was 1.51 (95% confidence interval [CI], 1.04, 2.18) for BCPR and 1.64 (95% CI, 1.16, 2.30) for TCPR. The multivariate adjusted odds ratio of favorable functional outcome at discharge was 1.58 (95% CI 1.05, 2.39) for BCPR and 1.56 (95% CI, 1.06, 2.31) for TCPR.

CONCLUSION

TCPR is independently associated with improved survival and improved functional outcome after OHCA.

Disparities in telephone CPR access and timing during out-of-hospital cardiac arrest

AIM

Spanish-only speaking residents in the United States face barriers to receiving potentially life-saving 911 interventions such as Telephone -cardiopulmonary resuscitation (TCPR) instructions. Since 2015, 911 dispatchers have placed an increased emphasis on rapid identification of potential cardiac arrest. The purpose of this study was to describe the utilization and timing of the 911 system during suspected out-of-hospital cardiac arrest (OHCA) by Spanish-speaking callers in Metropolitan Phoenix, Arizona.

METHODS

The dataset consisted of suspected OHCA from 911 centers from October 10, 2010 through December 31, 2013. Review of audio TCPR process data included whether the need for CPR was recognized by telecommunicators, whether CPR instructions were provided, and the time elements from call receipt to initiation of compressions.

RESULTS

A total of 3398 calls were made to 911 for suspected OHCA where CPR was indicated. A total of 39 (1.2%) were determined to have a Spanish language barrier. This averages to 18 calls per year with a Spanish language barrier during the study period, compared with 286 OHCAs expected per year among this population. The average time until telecommunicators recognized CPR need was 87.4s for the no language barrier group compared to 160.6s for the Spanish-language barrier group (p<0.001).Time to CPR instructions started was significantly different between these groups (144.4s vs 231.3s, respectively) (p<0.001), as was time to first compression, (174.4s vs. 290.9s, respectively) (p<0.001).

CONCLUSIONS

Our study suggests that Hispanic callers under-utilize the 911 system, and when they do call 911, there are significant delays in initiating CPR.

Delivering 9-1-1 CPR Instructions to Limited English Proficient Callers: A Simulation Experiment

Having 911 telecommunicators deliver CPR instructions increases cardiac arrest survival, but limited English proficiency (LEP) decreases the likelihood callers will perform CPR and increases time to first compression. The objective of our study was to assess which 9-1-1 CPR delivery modes could decrease time to first compression and improve CPR quality for LEP callers. 139 LEP Spanish and Chinese speakers were randomized into three arms: receiving CPR instructions from a 9-1-1 telecommunicator (1) with telephone interpretation, (2) using alternative, simple ways to rephrase, or (3) who strictly adhered to protocol language. Time interval from call onset to first compression, and CPR quality were the main outcomes. The CPR quality was poor across study arms. Connecting to interpreter services added almost 2 min to the time. CPR training in LEP communities, and regular CPR training for phone interpreters may be necessary to improve LEP bystander CPR quality.

Chest compression rate measurement from smartphone video

Background

Out-of-hospital cardiac arrest is a life threatening situation where the first person performing cardiopulmonary resuscitation (CPR) most often is a bystander without medical training. Some existing smartphone apps can call the emergency number and provide for example global positioning system (GPS) location like Hjelp 113-GPS App by the Norwegian air ambulance. We propose to extend functionality of such apps by using the built in camera in a smartphone to capture video of the CPR performed, primarily to estimate the duration and rate of the chest compression executed, if any.

Methods

All calculations are done in real time, and both the caller and the dispatcher will receive the compression rate feedback when detected. The proposed algorithm is based on finding a dynamic region of interest in the video frames, and thereafter evaluating the power spectral density by computing the fast fourier transform over sliding windows. The power of the dominating frequencies is compared to the power of the frequency area of interest. The system is tested on different persons, male and female, in different scenarios addressing target compression rates, background disturbances, compression with mouth-to-mouth ventilation, various background illuminations and phone placements. All tests were done on a recording Laerdal manikin, providing true compression rates for comparison.

Results

Overall, the algorithm is seen to be promising, and it manages a number of disturbances and light situations. For target rates at 110 cpm, as recommended during CPR, the mean error in compression rate (Standard dev. over tests in parentheses) is 3.6 (0.8) for short hair bystanders, and 8.7 (6.0) including medium and long haired bystanders.

Conclusions

The presented method shows that it is feasible to detect the compression rate of chest compressions performed by a bystander by placing the smartphone close to the patient, and using the built-in camera combined with a video processing algorithm performed real-time on the device.

Telephone-assisted CPR: A literature review

Introduction

Despite numerous efforts, out-of-hospital cardiac arrest (OHCA) survival has not significantly increased in recent decades. The first telephone-assisted cardiopulmonary resuscitation (T-CPR) studies were published in the 1980s, but only in the last decade has T‑CPR been implemented in dispatch centers. T‑CPR is still not available in all dispatch centers and no national or international T‑CPR recommendations are available.

Methods

Studies from PubMed were identified and evaluated. Preliminary information from the European Dispatch Center Survey (EDiCeS) is also included.

Results

In all, 42 studies were included. T‑CPR is implemented in 87.6 % of those dispatch centers which have joined the not-yet published EDiCeS. According to German Resuscitation Registry data, about 10 % of OHCA patients received T‑CPR in 2014. Agonal breathing is the leading cause for nonrecognition of OHCA by the dispatcher. Sensitivity of OHCA recognition by the dispatcher is about 75 %, whereby 8–45 % of these patients were not in cardiac arrest. The time interval from call to first compression is 140–328 s. Instructing rescue breathing by telephone is time consuming, leads to extensive hands-off times, and often to ineffective ventilation; therefore, rescue breathing is not indicated in adults with primary cardiac arrest. Studies showed improved survival with standardized T‑CPR implementation.

Conclusion

T-CPR is established in many dispatch centers. However, emergency call interrogation and T‑CPR vary between dispatch centers and are often performed without evaluation. International recommendations with standardized quality control are necessary and may lead to improved survival.

Sudden Cardiac Death in the Young

Although the occurrence of sudden cardiac death (SCD) in a young person is a rare event, it is traumatic and often widely publicized. In recent years, SCD in this population has been increasingly seen as a public health and safety issue. This review presents current knowledge relevant to the epidemiology of SCD and to strategies for prevention, resuscitation, and identification of those at greatest risk. Areas of active research and controversy include the development of best practices in screening, risk stratification approaches and postmortem evaluation, and identification of modifiable barriers to providing better outcomes after resuscitation of young SCD patients. Institution of a national registry of SCD in the young will provide data that will help to answer these questions.

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.

Mortality in Spanish pediatric emergency departments: a 5-year multicenter survey

BACKGROUND

Analysis of the causes of death in children in the pediatric emergency department (ED) may aid the development of management and prevention practices.

OBJECTIVE

To identify the causes of death in Spanish pediatric EDs and to analyze the management of these children in the prehospital and hospital settings.

METHODS

This was a retrospective descriptive multicenter survey including all patients whose death was certified in 18 Spanish pediatric EDs between 2008 and 2013.

RESULTS

During the study period, 3 542 426 episodes were registered in the EDs. Of these, 54 patients died (mortality rate: 1.5/100 000 visits). Data of 53 patients are analyzed (male 36, 67%, 31 younger than 2 years old and 43.3% nonpreviously healthy children). The main causes of death were related to their previous illnesses (24.5%), sudden infant death syndrome (20.7%), and traumatism (18.8%).Prehospital cardiopulmonary resuscitation (CPR) was performed in 31 patients, and exclusively by health workers in 19 patients. In 35 patients, the parents witnessed the event and seven began CPR.Thirty children were transferred to the pediatric EDs by medical transport (56.6%) and all of them received prehospital CPR (vs. one patient out of 23 arrived in a nonmedical transportation).In 37 patients, CPR was performed in the pediatric EDs. Overall, CPR lasted 40±23 min (range, 10-120 min). CPR was not performed in seven patients at any time.

CONCLUSION

The main causes of death in Spanish pediatric EDs are related to previous illnesses, sudden infant death syndrome, and nonintentional lesions. Several actions have to be considered to improve the quality of care of these children in prehospital and emergency settings.

Telephone CPR Instructions in Emergency Dispatch Systems: Qualitative Survey of 911 Call Centers

Introduction

Out-of-hospital cardiac arrest (OHCA) is a leading cause of death. The 2010 American Heart Association Emergency Cardiovascular Care (ECC) Guidelines recognize emergency dispatch as an integral component of emergency medical service response to OHCA and call for all dispatchers to be trained to provide telephone cardiopulmonary resuscitation (T-CPR) pre-arrival instructions. To begin to measure and improve this critical intervention, this study describes a nationwide survey of public safety answering points (PSAPs) focusing on the current practices and resources available to provide T-CPR to callers with the overall goal of improving survival from OHCA.

Methods

We conducted this survey in 2010, identifying 5,686 PSAPs; 3,555 had valid e-mail addresses and were contacted. Each received a preliminary e-mail announcing the survey, an e-mail with a link to the survey, and up to three follow-up e-mails for non-responders. The survey contained 23 primary questions with sub-questions depending on the response selected.

Results

Of the 5,686 identified PSAPs in the United States, 3,555 (63%) received the survey, with 1,924/3,555 (54%) responding. Nearly all were public agencies (n=1,888, 98%). Eight hundred seventy-eight (46%) responding agencies reported that they provide no instructions for medical emergencies, and 273 (14%) reported that they are unable to transfer callers to another facility to provide T-CPR. Of the 1,924 respondents, 975 (51%) reported that they provide pre-arrival instructions for OHCA: 67 (3%) provide compression-only CPR instructions, 699 (36%) reported traditional CPR instructions (chest compressions with rescue breathing), 166 (9%) reported some other instructions incorporating ventilations and compressions, and 92 (5%) did not specify the type of instructions provided. A validation follow up showed no substantial difference in the provision of instructions for OHCA by non-responders to the survey.

Conclusion

This is the first large-scale, nationwide assessment of the practices of PSAPs in the United States regarding T-CPR for OHCA. These data showing that nearly half of the nation’s PSAPs do not provide T-CPR for OHCA, and very few PSAPs provide compression-only instructions, suggest that there is significant potential to improve the implementation of this critical link in the chain of survival for OHCA.

[Drowning versus cardiac ischemia: Cardiac arrest of an 11-year-old boy at a swimming lake]

This report describes a case of sudden cardiac arrest and subsequent attempted cardiopulmonary resuscitation of an 11-year-old child on the shores of a swimming lake. Reports of eyewitnesses excluded the obviously suspected diagnosis of a drowning accident. The result of the autopsy was sudden cardiac death due to a congenital coronary anomaly (abnormal left coronary artery, ALCA). Favored by vigorous physical activity, this anomaly can lead to malignant arrhythmias because the ectopic coronary artery with its intramural course through the aortic wall is compressed during every systole. This pathology was not known to the boy or his family; in fact he liked sports but had suffered of a syncope once which was not followed up. Without a strong suspicion it is difficult to diagnose a coronary artery anomaly and it is often missed even in college athletes. Tragically, sudden cardiac arrest may be the first symptom of an undiagnosed abnormal coronary artery. Following syncope or chest pain during exercise with a normal electrocardiogram (ECG) cardiac imaging, such as computed tomography (CT) or angiography should be initiated in order to enable surgical repair of an abnormal coronary artery.