In out-of-hospital cardiac arrest, is the positioning of victims by bystanders adequate for CPR? A cohort study

ObjectivesOutcome from out-of-hospital cardiac arrest (OHCA) highly depends on bystander cardiopulmonary resuscitation (CPR) with high-quality chest compressions (CCs). Precondition is a supine position of the victim on a firm surface. Until now, no study has systematically analysed whether bystanders of OHCA apply appropriate positions to victims and whether the position is associated with a particular outcome.DesignProspective observational cohort study.SettingMetropolitan emergency medical services (EMS) serving a population of 400 000; dispatcher-assisted CPR was implemented. We obtained information from the first EMS vehicle arriving on scene and matched this with data from semi-structured interviews with witnesses of the arrest.ParticipantsBystanders of all OHCAs occurring during a 12-month period (July 2006–July 2007). From 201 eligible missions, 200 missions were fully reported by EMS. Data from 138 bystander interviews were included.Primary and secondary outcome measuresProportion of positions suitable for effective CCs; related survival with favourable neurological outcome at 3 months.ResultsPositioning of victims at EMS arrival was ‘supine on firm surface’ in 64 cases (32.0%), ‘recovery position (RP)’ in 37 cases (18.5%) and other positions unsuitable for CCs in 99 cases (49.5%). Survival with favourable outcome at 3 months was 17.2% when ‘supine position’ had been applied, 13.5% with ‘RP’ and 6.1% with ‘other positions unsuitable for CCs’; a statistically significant association could not be shown (p=0.740, Fisher’s exact test). However, after ‘effective CCs’ favourable outcome at 3 months was 32.0% compared with 5.3% if no actions were taken. The OR was 5.87 (p=0.02).ConclusionIn OHCA, two-thirds of all victims were found in positions not suitable for effective CCs. This was associated with inferior outcomes. A substantial proportion of the victims was placed in RP. More attention should be paid to the correct positioning of victims in OHCA. This applies to CPR training for laypersons and dispatcher-assisted CPR.</jats:sec

Official lay basic life support courses in Germany: is delivered content up to date with the guidelines? An observational study

BACKGROUND AND OBJECTIVES Educating the lay public in basic life support (BLS) is a cornerstone to improving bystander cardiopulmonary resuscitation (CPR) rates. In Germany, the official rescue organisations deliver accredited courses based on International Liaison Committee on Resuscitation (ILCOR) guidelines to up to 1 million participants every year. However, it is unknown how these courses are delivered in reality. We hypothesised that delivered content might not follow the proposed curriculum, and miss recent guideline updates. METHODS We analysed 20 official lay BLS courses of 240 min (which in Germany are always embedded into either a 1-day or a 2-day first aid course). One expert rated all courses as a participating observer, remaining incognito throughout the course. Teaching times for specific BLS elements were recorded on a standardised checklist. Quality of content was rated by 5-point Likert scales, ranging from -2 (not mentioned) to +2 (well explained). RESULTS Median total course time was 101 min (range 48-138) for BLS courses if part of a 1-day first aid course, and 123 min (53-244) if part of a 2-day course. Median teaching time for CPR was 51 min (range 20-70) and 60 min (16-138), respectively. Teaching times for recovery position were 44 min (range 24-66) and 55 min (24-114). Quality of content was rated worst for 'agonal gasping' (-1.35) and 'minimising chest compression interruptions' (-1.70). CONCLUSIONS Observed lay BLS courses lasted only half of the assigned curricular time. Substantial teaching time was spent on non-evidence-based interventions (eg, recovery position), and several important elements of BLS were not included. The findings call for curriculum revision, improved instructor training and systematic quality management

The Accuracy of an Out-of-Hospital 12-Lead ECG for the Detection of ST-Elevation Myocardial Infarction Immediately After Resuscitation

Study objective: Severe myocardial ischemia is the leading cause of arrhythmic sudden cardiac death. It is unclear, however, in which percentage of patients sudden cardiac death is triggered by ST-elevation myocardial infarction (STEMI) and whether the diagnosis of STEMI can be reliably established immediately after resuscitation from out-of-hospital sudden cardiac death. Methods: A 12-lead ECG was registered after return of spontaneous circulation after cardiac arrest. After hospital admission, further ECG, creatine kinase MB, and troponin measures; results of coronary angiograms; and autopsies were evaluated to confirm the definitive diagnosis of STEMI. Results: Seventy-seven patients were included in our study (67% men, age 64 [14 to 93] years). STEMI was diagnosed in 44 patients. The diagnosis of myocardial infarction was confirmed in 84% of the 77 patients who survived to hospital admission. The sensitivity of the out-of-hospital ECG was 88% (95% confidence interval [CI] 74% to 96%), the specificity 69% (95% CI 51% to 83%), the positive predictive value 77% (95% CI 62% to 87%), and the negative predictive value 83% (95% CI 64% to 87%). The accuracy of the out-of-hospital ECG and that registered on admission was the same. Conclusion: The diagnosis of STEMI can be established in the field immediately after return of spontaneous circulation in most patients. This may enable an early decision about reperfusion therapy, ie, immediate out-ofhospital thrombolysis or targeted transfer for percutaneous coronary intervention