Basic Life Support Defibrillation Research Articles

Should basic life support-defibrillator training be compulsory for newly licensed Italian physicians? An observational study.

Out-of-hospital cardiac arrest (OHCA) is a relevant event with a fatal outcome in most cases. Basic life support-defibrillator (BLSD) training is central to rescuing a patient in arrest and ensuring that the patient has a better chance of returning to spontaneous circulation. Despite this, BLSD training is not mandatory for newly licensed physicians. Our study aims to evaluate the preparedness of newly qualified doctors to manage an OHCA and the impact of BLSD training. We tested 120 newly qualified doctors, members of the 'Italian Society of Medicine and Scientific Divulgation' network, evaluating their practical and theoretical knowledge in managing an OHCA before and after a BLSD training course conducted according to the American Heart Association guidelines. Fifty-nine physicians (49.2%) had an adequate background of the theoretical basis of cardiopulmonary resuscitation (CPR); 37 (30.8%) were able to perform effective CPR on a mannequin, but only 19 (15.8%) were able to perform effective CPR with adequate depth and frequency of compressions. After the BLSD training course, 111 physicians (92.5%) were able to perform effective and quality CPR on a mannequin with feedback. In Italy, BLSD training for physicians is not mandatory, and newly licensed physicians showed good knowledge of the theoretical basis of CPR, but few of them performed compressions of adequate depth and frequency. These results should guide future educational policy decisions in Italian academies.

32 Basic Life Support Defibrillation Training in Trentino (Italy)

32 Basic Life Support Defibrillation Training in Trentino (Italy)

Missed training, collateral damage from COVID 19?

during the COVID-19 pandemic a total lockdown was enforced all over Italy starting on March 9th. This resulted in the shrinking of economic activities. In addition, all formal occupational security-training courses were halted, among them the 81/08 law lectures and Basic Life Support-Defibrillation (BLS-D) laymen training courses. The aim of the study was to evaluate the impact of the pandemic on BLS-D laymen training courses in the Lombardy region. BLS-D training courses records for the Lombardy region were analysed. The analysis was conducted from 2016 to 2020 as part of the Hippo project. between 2017 and 2019 BLS-D trained laymen kept increasing, moving from 53,500 trained individuals up to 74,700. In 2020 a stark reduction was observed with only 22,160 individuals trained. Formal courses were not halted completely during 2020. Still, in the months available for training, the number of individuals enrolled showed a sharp 50% reduction. laymen training courses for emergency management are a fundamental component of primary prevention practice. The 81/08 and 158/12 Italian laws have decreed this practice mandatory on the workplace. Following the enforcement of the lockdown and the subsequent interruption of emergency management courses, efforts will be necessary to re-establish and guarantee the high quality training of the pre-pandemic period.

Good-hearted people, Busca cardio-protected city: an evidence-based public access defibrillation project

Due to the scientific shreds of evidence, in sustain of the public access defibrillation (PAD) as an essential strategy to save the lives of those stricken by out-of-hospital cardiac arrest (OHCA), we accomplished a PAD project in Busca (CN), a small and beautiful city in the north-west of Italy. The program consists of providing several AEDs located in public places and the training of a large number of common citizens in basic life support & defibrillation (BLSD) manoeuvres. Here we present data about the lay population that participated in the courses and we discuss the main issues and possible limitations to the further development of PAD projects. This project aims to be an example to other cities who could be inspired by our experience.

Cardiac DeatH Prevention by aUtomated DefibrillatoRs in ChurcHes: Rationale and design of the CHURCH trial

Early defibrillation programs by the use of automated external defibrillators (AEDs) located in high-attendance public places may improve survival and neurologic outcome of patients undergoing sudden cardiac arrest (SCA). We planned a prospective cohort study to assess the effectiveness of a public-access defibrillation program based on positioning of AEDs in churches and training of lay volunteers in Basic Life Support Defibrillation during a single-day 5-hour training session. The CHURCH project aims to promote a widespread diffusion of AEDs, to train a large number of lay volunteers in Basic Life Support Defibrillation, and to increase population awareness on the opportunities for sudden death prevention. The rationale of the study rests on a survey commissioned by the Diocese of Milan that found a high prevalence of elderly subjects (44.5% were >60 years old) attending holy services in the morning hours, when sudden death incidence peaks. The catchment areas of the 12 parishes included in the trial as of June 2008 include a population of 140,000. The projected incidence of AED-treatable SCA, based on the presence of trained volunteers in the churches during day hours, at the CHURCH participating sites was estimated at 8 episodes per year. To estimate an overall 30% mortality reduction from SCA after AED placement at the study sites with respect to conventional SCA management by the Emergency Medical Service, 25 SCA episodes will have to be treated during the 4-year study period. The CHURCH project might be of interest and applicable in every country where high-attendance worship places are present.

Simulation and training at the Bambino Gesù Children's Hospital

The use of simulation systems employing dummies may be considered to be the first step in advanced simulation using dedicated software. The interest in simulation has been inspired by experience gained in industries with a common complexity and intrinsic risk. Simulation plays a central role in enabling continuous training with rare clinical situations in which experience could not normally be gained. The development of specific devices and systems for paediatrics and neonatology has seen the use of simulators extended to paediatrics. Paediatric emergency care is a high-risk, low-frequency event and therefore an ideal field for simulation using advanced systems. This has led to the introduction of simulation in the Emergency Department of the Bambino Gesù Children's Hospital in order to ensure: the identification and assessment of organisational healthcare models; promotion and collaboration between medical departments and units; the elaboration and proposal of guidelines; the promotion of the technical–professional qualifications of staff members; and the planning and implementation of training and simulation activities. Thus, the medical and nursing staff of the Emergency and Admissions Department and the Emergency and Admissions/Pediatric Intensive Care Unit have trained 210 physicians/nurses on 14 Pediatric Basic Life Support Defibrillator courses every year and 50 physicians/nurses on two Pediatric Advanced Life Support courses every year, as well as running several simulation courses ‘in situ’. Role-play is a key element of the educational techniques that use simulation in situ and is an effective method of ensuring the active participation of trainees. Medical simulation in situ is a necessary component of paediatric care training. It is increasingly used at the Bambino Gesù Children's Hospital in the context of multidisciplinary team training for patient safety.

Defibrillation and the quality of layperson cardiopulmonary resuscitation—Dispatcher assistance or training?

Aims of the study To examine whether basic life support-defibrillation (BLS-D) training of laypersons enhances the speed of defibrillation and the quality of cardiopulmonary resuscitation (CPR) during a simulated ventricular fibrillation scenario compared with a situation where the care provider has no previous BLS-D training but receives dispatcher assistance with the use of an automated external defibrillator (AED) and the performance of CPR. Methods Fifty-two military conscripts of the Finnish Defence Forces who without previous medical education had been tested in a simulated cardiac arrest scenario with dispatcher assistance and thereafter received a 4-h BLS-D training. Six months later they were randomly divided to form teams of two and again tested in a similar scenario but without dispatcher assistance. The time interval from collapse to first shock, hands-off time and the quality of CPR were compared between the two tests. Results The quality of mouth-to-mouth ventilation was better after training, but there was only a minor improvement in the quality of compressions and the speed of defibrillation. Conclusions Training improved the quality of mouth-to-mouth ventilation performed by laypersons but had only a minor effect on defibrillation and the quality of compressions.

Comparison of termination-of-resuscitation guidelines for out-of-hospital cardiac arrest in Singapore EMS

Termination of resuscitation (TOR) in the field for out-of-hospital cardiac arrest (OHCA) can reduce unnecessary transport to hospital and increase availability of resources for other patients. To compare the performance of three TOR guidelines for Basic Life Support-Defibrillator (BLS-D) providers when applied to cardiac arrest patients in the Cardiac Arrest and Resuscitation Epidemiology (CARE) study. This prospective cohort study involved all OHCA patients attended by BLS-D providers in a large urban center. The data analyses were conducted secondarily on these prospectively collected data. Three TOR guidelines proposed by Marsden et al. [BMJ 1995;311:49-51], Petrie [CJEM 2001;3:186-92] and Verbeek et al. [Acad Emerg Med 2002;9:671-8] were applied to show the relationship between the guidelines and actual survival. From 1 October 2001 to 14 October 2004, 2269 patients were enrolled into the study. Thirty-two (1.4%) survived to hospital discharge. For the 3 TOR guidelines, sensitivity was 93.8% (95%CI=79.9-98.3) (Petrie), 81.3% (95%CI=64.7-91.1) (Verbeek) and 90.6% (95%CI=75.8-96.8) (Marsden). Negative predictive value was 99.7% (95%CI=99.0-100.0) (Petrie), 99.6% (95%CI=99.2-99.8) (Verbeek) and 99.8% (95%CI=99.4-99.9) (Marsden). Application of these guidelines would have resulted in transport of 68.4% (Petrie), 31.3% (Verbeek) and 36.1% (Marsden) of cases. The Petrie guidelines would have recommended TOR in two patients who eventually survived. Similarly TOR was recommended in six patients for Verbeek and three patients for Marsden who eventually survived. We found all three TOR guidelines to have high sensitivity and negative predictive value. However the specificity and transport rates varied greatly. Application of any TOR guidelines may be affected by local EMS and population factors which should be considered in any policy decision.

Cost-effectiveness analysis of a rural/urban first-responder defibrillation program

Objective. To analyze the cost-effectiveness of a proposed first-responder defibrillation program in a small rural area in comparison with a recently initiated first-responder program in an adjoining urban center in southwestern Ontario. The purpose of the analysis was to quantify the expected benefits of the proposed program to determine whether the costs are justified. Methods. This analysis was conducted on the city of Waterloo (population 80,000 over 25 square miles) and the adjoining rural township of Wellesley (population 8,000 over 105 square miles). The township has volunteer fire department first responders with basic life support (BLS), and basic life support/defibrillation (BLS-D) ambulances as the second tier; whereas the city's full-time fire department has recently adopted a first-responder defibrillation (BLS-D) program backed up by the same BLS-D ambulance service. The most relevant costs identified were the capital costs of the defibrillators, ancillary equipment, and biomedical service for preventive maintenance and routine nonwarranty work. Response intervals and percentage of patients found in ventricular fibrillation were projected and sensitivity analysis was applied. Results. The projected cost per life saved is $6,776 (C) in the urban area and $49,274 (C) in the rural area using an incremental save rate of 6%. Applying sensitivity analysis to the data, the save rate varied from 2% to 10%, resulting in a cost per life saved of $20,328 (C) and $4,066 (C), respectively, in the urban community. For the rural area, the cost per life saved ranged from $147,821 (C) (2%) to $29,564 (C) (10%). Even the worst-case save rate for the urban center [2%; $20,328 (C)] is significantly less than the best-case save rate [10%; $29,564 (C)] for the rural area. Conclusions. The cost per life saved for a rural first-responder defibrillation program is significantly more expensive than one for an urban center. However, the cost per life saved is still economical compared with common treatments for other life-threatening illnesses. PREHOSPITAL EMERGENCY CARE 2000;4:43-47

Comparison of Termination-of-Resuscitation Guidelines for Basic Life Support: Defibrillator Providers in Out-of-Hospital Cardiac Arrest

Termination of resuscitation in the field for out-of-hospital cardiac arrest can reduce unnecessary transport to hospital and associated road hazards and increase availability of emergency medical services (EMS) and emergency department resources for other patients. We compare the performance of 3 termination-of-resuscitation guidelines for basic life support-defibrillator (BLS) providers when applied to cardiac arrest patients in the Ontario Prehospital Advanced Life Support study. This prospective cohort study involved all out-of-hospital cardiac arrest patients attended by BLS defibrillator providers in 21 Ontario urban or suburban communities. The data analyses were conducted secondarily on these prospectively collected data. Three termination-of-resuscitation guidelines (referred to as Marsden, Petrie, and Verbeek rules) were applied and contingency tables calculated to show the relationship between the rule and actual survival. From 1988 to 2003, 13,684 cardiac arrest patients were attended by BLS defibrillator providers. Six hundred thirty-six (4.7%) patients survived to hospital discharge. For the 3 termination-of-resuscitation rules, sensitivity was 99.8% (95% confidence interval [CI] 99.5% to 100.0%) (Petrie rules), 99.5% (95% CI 99.0% to 100.0%) (Verbeek rules), and 99.8% (95% CI 99.5% to 100.0%) (Marsden rules). Specificity was 9.9% (95% CI 9.4% to 10.4%) (Petrie rules), 52.9% (95% CI 52.1% to 53.8%) (Verbeek rules), and 19.4 % (95% CI 18.8% to 20.1%) (Marsden rules). Negative predictive value was 99.9% (95% CI 99.8% to 100.0%) (Petrie rules), 100.0% (95% CI 99.9% to 100.0%) (Verbeek rules), and 100.0% (95% CI 99.9% to 100.0%) (Marsden rules). These rules would have resulted in field termination of resuscitation in 9.4% (Petrie rules), 50.5% (Verbeek rules), and 18.5 % (Marsden rules) of cases. Termination of resuscitation was recommended for 1 patient (Petrie rules), 3 patients (Verbeek rules), and 1 patient (Marsden rules), who survived. We found all 3 termination-of-resuscitation rules to have high sensitivity and negative predictive value. However, the specificity and transport rates varied greatly. The results of this study will be useful for EMS providers considering adoption of termination of resuscitation in BLS defibrillator systems for out-of-hospital cardiac arrest.

Comparison of Termination-of-resuscitation Guidelines for Basic Life Support-Defibrillator Providers in out-of-hospital Cardiac Arrest

Comparison of Termination-of-resuscitation Guidelines for Basic Life Support-Defibrillator Providers in out-of-hospital Cardiac Arrest

Temporal trends in sudden cardiac arrest: a 25-year emergency medical services perspective.

Little is known about temporal trends in survival and prognostic characteristics of patients with out-of-hospital cardiac arrest treated by emergency medical services (EMS). We hypothesized that an evolving combination of beneficial and adverse factors may contribute to temporal patterns of survival. We evaluated a population-based cohort of EMS-treated adult patients with cardiac arrest (n=12 591) from 1977 to 2001 in King County, Washington. Time was grouped into an initial 5-year period and 5 successive 4-year periods. We sought to determine the potential impact of temporal changes in prognostic factors typically beyond EMS control termed "fate" factors (for example, patient age) and factors implemented by EMS termed "program" factors (programs of dispatcher-assisted cardiopulmonary resuscitation and basic life support defibrillation). Several characteristics associated with survival changed over time. Observed survival did not change over time among all patients with cardiac arrest (OR=0.98 [0.95, 1.01], trend for each successive time period) and improved over time among patients with witnessed ventricular fibrillation (OR=1.05 [1.01, 1.09]). In models that included all patients with cardiac arrest and controlled for fate factors, advancing time period was associated with an increase in survival (OR=1.08 [1.05, 1.11]). Conversely, in models that controlled for program factors, advancing time period was associated with a decrease in survival (OR=0.95 [0.93, 0.98]). Results were similar among patients with witnessed ventricular fibrillation. The static temporal pattern of survival from cardiac arrest appeared to result from an evolving balance of prognostic factors. Programs implemented by EMS appeared to counter adverse temporal trends in prognostic factors typically beyond EMS control.

Factors affecting survival after prehospital asystolic cardiac arrest in a Basic Life Support-Defibrillation system

Previous studies have shown a low but meaningful survival rate in cases of prehospital cardiac arrest with an initial rhythm of asystole. There may be, however, an identifiable subgroup in which resuscitation efforts are futile. This study identified potential field criteria for predicting 100% nonsurvival when the presenting rhythm is asystole in a Basic Life Support-Defibrillation (BLS-D) system. This prospective cohort study, a component of Phases I and II of the Ontario Prehospital Advanced Life Support (OPALS) Study, was conducted in 21 Ontario communities with BLS-D level of care, and included all adult arrests of presumed cardiac etiology according to the Utstein Style Guidelines. Analyses included descriptive and appropriate univariate tests, as well as multivariate stepwise logistic regression to determine predictors of survival. From 1991 to 1997, 9899 consecutive cardiac arrest cases with the following characteristics: male (67.2%), bystander-witnessed (44.7%), bystander CPR (14.2%), call response interval (CRI) </= 8 minutes (82%) and overall survival (4.3%) were enrolled. Of 9529 cases with available rhythm strip recordings, initial arrest rhythms were asystole in 40.8%, pulseless electrical activity in 21.2% and ventricular fibrillation or ventricular tachycardia in 38%. Of 3888 asystolic patients, 9 (0.2%) survived to discharge; 3 of these cases were unwitnessed arrests with no bystander CPR. There were no survivors if the CRI exceeded 8 minutes. Logistic regression analysis demonstrated that independent predictors of survival to admission were "CRI in minutes" (odds ratio [OR] = 0.87; 95% confidence interval [CI], 0.77-0.98) and "bystander-witnessed" (OR = 2.6; 95% CI, 1.5-4.4). In a BLS-D system, there is a very low but measurable survival rate for prehospital asystolic cardiac arrest. CRIs of over 8 minutes were associated with 100% nonsurvival, whereas unwitnessed arrests with no bystander CPR were not. These data add to the growing literature that will help guide ethical decision-making for protocol development in emergency medical services systems.

Chest compressions and basic life support–defibrillation

Chest compressions and basic life support–defibrillation

C OST -E FFECTIVENESS A NALYSIS OF A R URAL /U RBAN F IRST - RESPONDER D EFIBRILLATION P ROGRAM

Objective. To analyze the cost-effectiveness of a proposed first-responder defibrillation program in a small rural area in comparison with a recently initiated first-responder program in an adjoining urban center in southwestern Ontario. The purpose of the analysis was to quantify the expected benefits of the proposed program to determine whether the costs are justified. Methods. This analysis was conducted on the city of Waterloo (population 80,000 over 25 square miles) and the adjoining rural township of Wellesley (population 8,000 over 105 square miles). The township has volunteer fire department first responders with basic life support (BLS), and basic life support/defibrillation (BLS-D) ambulances as the second tier; whereas the city's full-time fire department has recently adopted a first-responder defibrillation (BLS-D) program backed up by the same BLS-D ambulance service. The most relevant costs identified were the capital costs of the defibrillators, ancillary equipment, and biomedical service for preventive maintenance and routine nonwarranty work. Response intervals and percentage of patients found in ventricular fibrillation were projected and sensitivity analysis was applied. Results. The projected cost per life saved is $6,776 (C) in the urban area and $49,274 (C) in the rural area using an incremental save rate of 6%. Applying sensitivity analysis to the data, the save rate varied from 2% to 10%, resulting in a cost per life saved of $20,328 (C) and $4,066 (C), respectively, in the urban community. For the rural area, the cost per life saved ranged from $147,821 (C) (2%) to $29,564 (C) (10%). Even the worst-case save rate for the urban center [2%; $20,328 (C)] is significantly less than the best-case save rate [10%; $29,564 (C)] for the rural area. Conclusions. The cost per life saved for a rural first-responder defibrillation program is significantly more expensive than one for an urban center. However, the cost per life saved is still economical compared with common treatments for other life-threatening illnesses.

Modifiable Factors Associated With Improved Cardiac Arrest Survival in a Multicenter Basic Life Support/Defibrillation System: OPALS Study Phase I Results

Study objectives: This study was conducted to identify modifiable factors associated with survival for prehospital cardiac arrest in a large, multicenter EMS system with basic life support/defibrillation (BLS-D) level of care. Methods: This observational cohort study constitutes Phase I of the 3-phase Ontario Prehospital Advanced Life Support (OPALS) Study. Included were all adults who had cardiac arrest before EMS arrival in 21 urban/suburban communities that operate under the jurisdiction of 1 ambulance services branch, have 911 telephone service, and provide ambulance defibrillation but no prehospital advanced life support (ALS). Central dispatch and ambulance records were reviewed according to the Utstein guidelines. Associations between multiple patient and EMS factors and survival to discharge were assessed by univariate then stepwise logistic regression analyses. Results: From January 1, 1991, to January 31, 1995, 5,335 eligible patients were treated. Of these, 46.8% of cardiac arrests were witnessed by citizens, 14.5% received bystander CPR, 25.6% received CPR by fire or police, and 38.2% had an initial rhythm of ventricular fibrillation/ventricular tachycardia (VF/VT). The mean interval from call received to vehicle stopped was 6.7 minutes. Survival was 3.5% overall and 8.8% for VF/VT. Multivariate analysis found the following factors to be independently associated with survival (odds ratio with 95% confidence intervals): age .81 (.73, .89), bystander-witnessed arrest 4.05 (2.78, 5.90), bystander CPR 2.98 (2.07, 4.29), CPR by fire or police 2.20 (1.46, 3.31), and response interval call received to vehicle stopped .76 (.71, .82). Conclusion: This represents the largest multicenter BLS-D study of prehospital cardiac arrest yet conducted and clearly indicates that patient survival may be improved by optimization of EMS response intervals, bystander CPR, as well as first-responder CPR by fire or police. [Stiell IG, Wells GA, DeMaio VJ, Spaite DW, Field BJ, Munkley DP, Lyver MB, Luinstra LG, Ward R, for the OPALS Study Group: Modifiable factors associated with improved cardiac arrest survival in a multicenter basic life support/defibrillation system: OPALS Study phase I results. Ann Emerg Med January 1999;33:44-50.]

Effect of Out-of-Hospital Defibrillation by Basic Life Support Providers on Cardiac Arrest Mortality: A Metaanalysis

See related editorial, "Effectiveness of Basic Life Support Defibrillation." Study objective: Although some studies demonstrate otherwise, we hypothesized that metaanalysis would demonstrate a reduction in the relative risk of mortality when basic life support (BLS) providers can defibrillate out-of-hospital cardiac arrest patients. Design: Metaanalysis of studies meeting the following criteria: single-tier or two-tier emergency medical service (EMS) system, survival to hospital discharge for patients in ventricular fibrillation, and manual and/or automatic external defibrillators. The aerror rate was .05. Results: Seven trials qualified for metaanalysis. Across all trials, the risk of mortality for BLS care with defibrillation versus that without was .915 (P =.0003). Separate subset analyses of single-tier and two-tier EMS systems demonstrated similar results. Conclusion: BLS defibrillation can reduce the relative risk of death for out-of-hospital cardiac arrest victims in ventricular fibrillation. Weaknesses in individual study designs and regional clustering limit the strength of this metaanalysis and conclusion. [Auble TE, Menegazzi JJ, Paris PM: Effect of out-of-hospital defibrillation by basic life support providers on cardiac arrest mortality: A metaanalysis. Ann Emerg Med May 1995;25:642-648.]