Double sequential defibrillation (DSD) is a promising treatment for patients with out-of-hospital cardiac arrest (OHCA) with refractory ventricular fibrillation. The reproducibility and generalisability of previous studies are unknown. Additionally, whether DSD could improve survival if applied earlier has never been studied. The DoubleD trial aims to establish whether early DSD (as soon as possible after the first shock) is superior to standard defibrillation. This pilot study evaluated the safety and feasibility of this strategy in preparation for the main trial. This Swedish, prehospital, open-label, randomised controlled external pilot trial enrolled patients with OHCA who were still in cardiac arrest after at least one defibrillation in the standard (anterior-lateral) position. Enrolment required two ambulances with manual defibrillators to be present. The inclusion goal was 40 patients, randomised 3:1 to early DSD (with a second defibrillator in the anterior-posterior position) or continued standard defibrillation. Data were collected from study questionnaires, medical charts and defibrillators. The main feasibility and safety outcomes were randomisation prior to three shocks, adherence to protocol and defibrillator malfunction. Between June 2024 and April 2025, 40 patients were randomised: 29 to early DSD and 11 to standard defibrillation. Overall, 32/40 (80%) were randomised before the third defibrillation. In the DSD group, 20/21 (95%) of patients who still had a shockable rhythm after randomisation received DSD. One case of treatment crossover occurred in both DSD and control groups. No defibrillator malfunctions or adverse events were observed. 30-day survival was 12/29 (41%) and 1/11 (9%) for the DSD and control group respectively. This is the first time that early DSD has been investigated in clinical practice. The strategy is feasible and appears to be safe. The findings have informed the design of the DoubleD main trial, powered to assess 30-day survival (NCT07174986). NCT06447805.

Emergency Medical Services Equipment Use in the Emergency Department and Time to Care for Those With Out-of-Hospital Cardiac Arrest.

In Korea, more than 30,000 out-of-hospital cardiac arrests (OHCAs) occur each year, and the survival rate remains below 10%. Because OHCA is difficult to predict and typically occurs outside medical facilities, effective management requires not only healthcare professionals but also laypersons, including bystanders and first responders. Survival depends on an uninterrupted and efficient sequence of time-critical actions: early recognition of cardiac arrest and activation of emergency services; prompt bystander cardiopulmonary resuscitation (CPR); use of an automated external defibrillator (AED) for shockable rhythms; on-scene and in-hospital advanced life support with comprehensive post–cardiac arrest care; and systematic assessment of neurologic and functional outcomes followed by rehabilitation and recovery. The chain of survival describes these essential steps required to maximize survival after cardiac arrest and comprises five links: (1) early recognition and call for help; (2) immediate bystander CPR; (3) early defibrillation with an AED; (4) advanced life support and post–cardiac arrest care; and (5) rehabilitation and recovery for survivors. The cardiac arrest survival environment represents a societal infrastructure that sustains and optimizes both medical and nonmedical factors across prevention, treatment, and rehabilitation to reduce mortality. Establishing such an environment requires each community to develop integrated medical systems for prevention, treatment, rehabilitation, and recovery, alongside nonmedical strategies, including public awareness initiatives, widespread CPR education and bystander participation, AED dissemination, and coordinated community responsiveness of the emergency medical system.

Real-time Geolocation Platforms for Access to Automated External Defibrillators in Out-of-Hospital Cardiac Arrest: A Scoping Review.

Drone-delivery of defibrillators reduces time to defibrillation in a ski resort: a randomised simulation-based trial

Resuscitation needs justice: an intersectional view on justice, equity, diversity, and inclusion.

Background: Pediatric out-of-hospital cardiac arrest (OHCA) is rare and associated with poor outcomes. Evidence from physician-staffed EMS systems remains limited. This study aimed to describe the incidence, presenting rhythms, EMS response intervals, and outcomes of pediatric OHCA, and to describe incidence, presenting rhythms, EMS response intervals, and prehospital outcomes in a local physician-staffed EMS system. Methods: We conducted a retrospective study of all pediatric (0-17 years) OHCA cases managed by the ASL Lecce physician-staffed EMS (southern Italy) between 2013 and 2025. Data were abstracted from standardized records. Variables included demographics, initial rhythm, EMS response intervals, temporal patterns, and return of spontaneous circulation (ROSC). The primary outcome was ROSC during prehospital care. Results: Twenty-seven cases were identified, corresponding to a cumulative incidence of 22.9 per 100,000 children over the study period (annualized incidence 1.73 per 100,000 children-year). Mean age was 11.9 ± 5.5 years (median 15); 59% were male. Initial rhythms were asystole in 81% and ventricular fibrillation (VF) in 19%; no pulseless ventricular tachycardia (pVT) or pulseless electrical activity (PEA) were recorded. Five patients had shockable rhythms, with seven shocks delivered overall. Mean time intervals were: event-to-call 1.0 ± 0.6 min, call-to-arrival 10.3 ± 4.1 min, event-to-arrival 11.3 ± 4.4 min. Arrests clustered during daytime (63%) and summer (41%). ROSC occurred in three patients (11%), two with VF and one with asystole; all arrests with ROSC were daytime events. In descriptive comparisons, ROSC cases showed a shorter call-to-arrival interval (T1-T2), whereas no consistent pattern was observed across all prehospital time intervals. Conclusions: Pediatric OHCA in this Italian physician-staffed EMS was infrequent, usually presented with asystole, and rarely achieved ROSC. Shockable rhythms were associated with better outcomes. Given the small sample size, findings related to response times should be interpreted with caution. System preparedness should include pediatric-specific training, early defibrillation access, and multicenter registries to improve care and track outcomes.

EMS protocol gaps for defibrillator pad placement in prehospital STEMI care.

Cardiac arrest occurs rapidly, requires high timeliness in treatment, and has a poor prognosis. Cardiopulmonary resuscitation (CPR) is a key intervention to save the lives of patients with cardiac arrest. In recent years, CPR has made significant progress with the update of evidence-based research and technological development. The evolution of specific recommendations in international guidelines reflects the changes in the certainty of and understanding about emerging evidence. To unravel the logical progression of cognitive development in the CPR field, this review systematically clarifies the evidence base and evolutionary history of recommendations for core components of adult CPR, including the chain of survival, interruptions in compressions, high-quality CPR, early defibrillation, dispatcher-assisted CPR, extracorporeal CPR, and temperature control. Moreover, it identifies knowledge gaps and proposes potential development directions to provide systemic insights and strategic thinking in CPR for providers, researchers, and healthcare administrators.

Immediate cardiopulmonary resuscitation and early defibrillation are key determinants of survival after out-of-hospital cardiac arrest (OHCA). Public access defibrillation (PAD) remains inconsistently implemented, with major gaps in automated external defibrillator (AED) availability, integration and use. This study aimed to identify and prioritise barriers and enablers to PAD implementation and to highlight emerging deployment models for future research. During the third International Community First Responder Symposium (April 2024, Hinterzarten, Germany), 46 experts from 14 countries participated in a structured RAND-UCLA Appropriateness Method consensus study. In moderated discussions, participants identified barriers and enablers to PAD, which were grouped into four thematic fields: availability and accessibility, usability and awareness, technological and systemic aspects, and financial and maintenance concerns. Nine statements were formulated and rated on a 9-point Likert scale; strong consensus was defined a priori as a median ≥ 7 with ≥ 80% of ratings in the 7-9 range. All nine statements met criteria for strong consensus. Key barriers included limited 24/7 AED access, poor coverage in residential areas, lack of centralised, real-time AED registries, insufficient public training and awareness, legal concerns for lay responders, patchy integration with emergency medical services, and device and maintenance costs. Key enablers comprised mandatory AED registration and live mapping, community training, legal protection for lay users, equipping police and fire services with AEDs within a "nearest vehicle" strategy, and improved data sharing between AEDs and hospitals. Experts also highlighted innovative deployment concepts, including use of postal and transport fleets, Vertical Take off and Landing drones, predictive positioning models and low-cost device designs. This international consensus study underscores the need for coordinated policy, robust AED registries, widespread training and multi-tier response models to improve PAD implementation. The identified priorities and innovative deployment strategies offer an agenda for future system development.

Rethinking Cardiac Arrest: New Paradigms in the 2025 ERC Guidelines.

Early bystander CPR and defibrillation improve cardiac arrest survival. International studies show women receive fewer bystander interventions after out-of-hospital cardiac arrest (OHCA) than men. We investigated associations between sex and bystander interventions in OHCA in Aotearoa New Zealand. Retrospective cohort study of adult OHCA with attempted resuscitation (January 2019-December 2023). Variables included demographics, ethnicity, socioeconomic deprivation, rurality, location type, and witness status. Logistic regression assessed associations between sex and bystander CPR and bystander defibrillation (shock delivered), adjusting for covariates. Of 9377 OHCA events, 29.6% occurred in females. Bystander CPR rates were similar between females (75.7%) and males (77.3%) (AOR 1.06, 95% CI: 0.94-1.18, p=0.36). However, bystander defibrillation occurred in only 1.9% of females versus 5.4% of males. Females had 65% lower odds of receiving bystander defibrillation in unadjusted analysis (UOR 0.35, 95% CI: 0.26-0.47, p<0.001) and 39% lower odds after adjustment (AOR 0.61, 95% CI: 0.44-0.84, p=0.002). Among shockable rhythm cases, sex disparity was not significant (AOR 0.83, 95% CI: 0.59-1.15, p=0.26). Despite equitable bystander CPR rates, females had significantly lower odds of receiving bystander defibrillation. In shockable rhythm cases, the disparity was not significant after adjustment for covariates, suggesting that patient and event characteristics mediate rather than confound this relationship. Findings highlight the need for targeted interventions addressing strategies to improve bystander defibrillation for females in cardiac arrest.

Background: Ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT) are time sensitive cardiac arrest rhythms where survival depends on rapid defibrillation. In the emergency department (ED), both out of hospital cardiac arrest (OHCA) arrivals and in ED and in-hospital cardiac arrest (IHCA) events may be encountered. The ED specific evidence base on early defibrillation is limited in ED cohorts and broader in hospital registries. Objective: our study aim to analyze original articles from PubMed Central on the association between early defibrillation and outcomes in VF and pVT cardiac arrest managed in ED settings. Methods: We followed PRISMA methods, structured question, reproducible search strategy, eligibility criteria, dual stage screening, standardized extraction, and narrative synthesis. We searched electronic databases for full-text on December 2026 for studies reporting VF and pVT arrests with a measurable defibrillation time variable (time to first shock, defibrillation within 2 minutes, or rhythm analysis before arrest team arrival). We included original human studies and excluded reviews, editorials, simulations, and single patient case reports. Results: Ten original studies met inclusion criteria, in ED-managed arrests, time to first defibrillation differ widely (median 2 to 3 minutes in one ED cohort with survivors vs non-survivors showing similar times, and 10 to 12 minutes in shockable cases in another ED based study). In a large adult IHCA registry analysis, defibrillation within 2 minutes was associated with better longer term survival reported as a 49% higher likelihood of 1 year survival. A pediatric IHCA registry analysis found no significant association between defibrillation time and survival to discharge. In Danish hospitals, rhythm analysis before cardiac arrest team arrival was associated with higher ROSC. Conclusion: our finding prioritize rapid defibrillation for VF/pVT, with strong adult in hospital registry signals favoring very early shocks (≤2 minutes), while ED-specific cohorts show variable timing and outcomes. Pediatric in-hospital data indicate that timing effects differ by age group or clinical context. Higher-quality ED-specific prospective studies were needed.

The Utstein Formula for Survival, the ethos of the American Heart Association's 2025 guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, is a conceptual model for survival of out-of-hospital cardiac arrest that equally weighs medical science, educational efficiency, and local implementation. With this formula in mind, the American Heart Association has put forth new guidelines that emphasize not only high-quality chest compressions and early defibrillation but also robust systems of care, equitable access, advanced resuscitation techniques, and postcardiac arrest recovery. The 2025 updates carry significant weight for health policy, clinical practice, education, and ethical discussions. In this review, we highlight the major changes, discuss their implications, and propose directions for future research and implementation.

Abstract: Cardiac arrest is a critical medical emergency whose management has evolved in parallel with scientific evidence and international guidelines issued by organizations such as the American Heart Association and the International Liaison Committee on Resuscitation. This article reviews the management of cardiac arrest in the intensive care unit, focusing on the initial assessment, life support interventions, and specific considerations unique to this setting. These include continuous monitoring, cardiopulmonary resuscitation in the prone position, the use of mechanical chest compression devices, and the pivotal role of capnography. The importance of an organized and rapid response is emphasized, with early defibrillation and prompt identification of reversible causes using ultrasonography and other diagnostic tools as key priorities. Special considerations related to patients receiving mechanical ventilation, airway management, and the impact of pharmacotherapy are also discussed. Finally, adaptations required in special scenarios, such as patients supported with extracorporeal membrane oxygenation or those in the postoperative period following thoracic surgery—are highlighted. Proper implementation of these strategies may improve rates of return of spontaneous circulation and survival among patients experiencing cardiac arrest in the intensive care unit. Cardiac arrest is a quintessential medical emergency; therefore, well-established global guidelines exist, including those from the American Heart Association and the International Liaison Committee on Resuscitation. Over time, and with the accumulation of scientific evidence, protocols for basic and advanced life support have evolved, with some of the most significant changes occurring during the COVID-19 pandemic. Accordingly, this review focuses specifically on the intensive care unit as the clinical setting of interest.

Out-of-hospital cardiac arrest (OHCA) survival depends critically on early defibrillation. Coordinated automated external defibrillator (AED) systems, including registries, mapping initiatives, and integration with emergency medical services (EMS), enable real-time device location, strategic placement, and system-level quality improvement. However, implementation varies widely between countries. To synthesize evidence on the impact of coordinated AED systems, including registries and public-access defibrillation programs, on OHCA outcomes and to identify lessons from Japan applicable to Poland. A systematic review was conducted according to PRISMA guidelines. PubMed/MEDLINE, EMBASE, Cochrane Library, and Scopus were searched (January 2015-June 2025) for studies evaluating AED registries, mapping systems, and public-access defibrillation programs. Eligible designs included randomized trials, observational registry studies, economic evaluations, and policy analyses. Inclusion criteria comprised studies evaluating AED registries, mapping systems, or public-access defibrillation in OHCA settings with reported clinical, operational, or economic outcomes. Exclusion criteria included studies without primary data, conference abstracts without full text, animal studies, and studies focused solely on in-hospital cardiac arrest. Study quality was assessed using the Newcastle-Ottawa Scale, AMSTAR 2, and CHEERS 2022. Seventeen studies met inclusion criteria. Japan's coordinated system, combining nationwide OHCA surveillance, public-access defibrillation programs, AED mapping initiatives, and EMS integration, has been associated in observational studies with increased bystander AED use among patients with bystander-witnessed OHCA with shockable rhythm (from 1.1 to 16.5%), reduced time to defibrillation, and improved neurological outcomes. In contrast, Poland currently lacks a fully coordinated national system, resulting in fragmented AED data and limited integration with emergency response. Modeling studies suggest that implementing a national system incorporating an AED registry, dispatcher integration, and community responder networks would be cost-effective. Coordinated AED systems, rather than standalone registries, represent an effective system-level approach to improving OHCA outcomes. Japan's experience highlights the importance of integrating AED mapping, OHCA surveillance, EMS systems, and public training. Implementing such a coordinated approach in Poland could substantially improve survival and neurological outcomes after cardiac arrest. However, the observed benefits are likely multifactorial and reflect the combined effect of system-level interventions rather than a single component.

Sudden cardiac death (SCD) is a rare but devastating event in the sports setting, often affecting apparently healthy and physically active individuals. Although regular physical activity is widely promoted as a protective factor against cardiovascular disease, cases of SCD continue to be reported not only in elite athletes but also in amateur and recreational athletes, who frequently lack systematic cardiovascular screening. To map the available evidence on the most prevalent cardiovascular diseases and the associated risk factors related to sudden cardiac death in amateur athletes. A scoping review was conducted following the PRISMA-ScR guidelines and the methodological framework proposed by the Joanna Briggs Institute (JBI). The research question was structured using the PCC framework (Population: amateur athletes aged ≥18 years; Concept: cardiovascular diseases and associated risk factors; Context: sudden cardiac death). Systematic searches were performed in PubMed, Scopus, SciELO, and Springer, with no restrictions on publication date and including studies published in English, Spanish, and Portuguese. Study selection, data extraction, and methodological quality assessment were independently performed by two reviewers, with disagreements resolved by a third reviewer. Methodological quality was assessed using JBI critical appraisal tools for observational cohort studies. A total of 1,807 records were identified, of which five observational studies met the inclusion criteria. The most frequently reported cause of SCD in amateur athletes was hypertrophic cardiomyopathy, followed by atherosclerotic coronary artery disease-particularly in athletes older than 35 years-and myocarditis, mainly in younger individuals with recent respiratory infections. Football was the sport most commonly associated with SCD events. The main risk factors identified included male sex, intense physical exertion, traditional cardiovascular risk factors (smoking, hypertension, dyslipidemia, prior myocardial infarction, and coronary stenosis), family history of premature coronary disease, and the absence of early cardiopulmonary resuscitation or defibrillation at the event site. Overall methodological quality ranged from moderate to high. Sudden cardiac death in amateur athletes is predominantly associated with underlying cardiovascular diseases, particularly hypertrophic cardiomyopathy, and with a combination of modifiable and non-modifiable risk factors. These findings highlight that SCD is not exclusive to elite sports and underscore the need for preventive strategies in amateur athletes, including cardiovascular screening, risk factor control, education in cardiopulmonary resuscitation, and availability of automated external defibrillators in sports settings.

Accurate identification of cardiac rhythm during cardiopulmonary arrest (CPA) is crucial for patient survival. According to American Heart Association guidelines [1–3], early defibrillation is essential for shockable rhythms—ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT)—while early epinephrine administration is required for non-shockable rhythms such as pulseless electrical activity (PEA) and asystole. This quasi-experimental pretest/posttest study aimed to compare rhythm recognition before and after simulation-based training. Seventy-five incoming pediatric residency physicians participated (final posttest sample: 53). Three rhythm-identification items—sinus bradycardia/PEA, VT, and VF—were evaluated in both assessments. Training took place within an intensive course on pediatric emergency assessment and initial management. Pretest results showed correct recognition rates of 88% for VF, 84% for PEA, and 73.3% for pulseless VT. Posttest data demonstrated improved discrimination between shockable and non-shockable rhythms, particularly by eliminating confusion between PEA and shockable rhythms. However, persistent errors in rhythm interpretation and a statistically significant decline in VF recognition highlighted important weaknesses. These findings underscore the need for more comprehensive and targeted training to ensure rapid and appropriate decisions during CPA. Although simulation was beneficial in specific aspects, its overall effectiveness for consolidating precise rhythm identification was limited. Future iterations of the program should incorporate a dedicated rhythm-recognition station and longitudinal reinforcement strategies.

Early defibrillation significantly improves survival following out-of-hospital cardiac arrest. Public access automated external defibrillators (AEDs) facilitate rapid shock delivery, enhancing survival rates and neurological outcomes. Language barriers may impede the effectiveness of these devices, particularly in multilingual environments. This study aimed to evaluate AED operation skills and time during a simulated cardiac arrest scenario, comparing native language instructions (Spanish: AEDnative) with foreign language instructions (English: AEDforeign). A randomized pilot study was conducted with 50 Spanish-speaking university students (42% female, median age: 21 years) with no prior AED training and a minimum B1 level of foreign language proficiency (English). Participants were randomly assigned to either the AEDnative or AEDforeign group. The simulated cardiac arrest scenario was performed on a mannequin using a multilingual AED trainer. AED performance, response times, language proficiency, and demographic data were recorded. Participant actions were video-recorded and analyzed using observational methodology. Both groups achieved high completion rates (>70%) in most AED operation steps. However, the AEDnative group performed significantly better in two critical safety actions: ensuring no one touched the victim before shock (96% vs. 12%) and initiating CPR after shock delivery (83% vs. 12%). No differences were found in the time to pad placement, but the AEDforeign group delivered the shock significantly faster after pad placement (19 s vs. 33 s; P = 0.016). AED use remains feasible, even in a nonnative language; however, foreign-language instructions may compromise performance safety and delay or omit postshock CPR initiation.

BackgroundOut-of-hospital cardiac arrest (OHCA) remains a major global health challenge with persistently low survival rates despite advances in resuscitation science. This study aimed to evaluate the epidemiology, management, and outcomes of OHCA in Qatar using a national registry aligned with Utstein reporting standards.MethodsA prospective observational cohort study was conducted across Qatar, enrolling all adult patients (≥18 years) with non-traumatic OHCA in whom resuscitation was attempted by the national EMS provider. Data were collected from EMS records, hospital EMRs, and mortuary databases. Survivors were followed up at 30 days and 12 months for neurological and quality-of-life outcomes. The primary outcome was 30-day survival with a favourable neurological status (CPC 1–2).ResultsAmong 1238 OHCA cases, the median age was 52 years, and 80.5 % were male. Arrests occurred predominantly at home (64.0 %), with 61.8 % witnessed and 42.4 % receiving bystander CPR. Initial shockable rhythms were present in 29.7 %. ROSC was achieved in 44.8 %, survival to discharge was 17.8 %, and a favourable neurological outcome at 30 days was 13.5 %. Multivariable analysis identified witnessed arrest, prehospital defibrillation, and coronary reperfusion within 24 h as independent predictors of survival. The Utstein comparator group demonstrated a survival rate of 38.2 % and CPC 1–2 outcome in 32.8 % of cases.ConclusionsOHCA outcomes in Qatar have improved markedly, with survival and CPC 1–2 rates more than doubling compared with prior national estimates. Survival now approaches levels seen in high-performing international systems, although within a younger patient population. Consistent predictors of outcome—including witnessed arrest, early defibrillation, and timely coronary reperfusion—emphasise the critical targets for strengthening OHCA systems of care.