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Stayin' alive -- delivering resuscitation messages to the public

Teaching bystander Cardiac Pulmonary Resuscitation (CPR) strategically to the general public offers the greatest potential to make the biggest overall impact on survival in out of hospital cardiac arrests in Europe, reported a main session on Resuscitation Science at the European Society of Cardiology's EuroHeart Care Congress, which took place in Glasgow, 22 to 23 March, 2013.

"The reality is that four out of five cardiac arrests happen at home, and unless the public are trained in resuscitation many people die before emergency services get to them," said Mary Hannon. "The good news is that CPR is an important life saving technique that can be effectively taught to most people."



It is estimated that a victim's chance of survival slips away by 7% to 10% each minute before CPR is started. "So it's vital not to procrastinate. The challenge is to persuade everyone to roll up their sleeves and get stuck in as quickly as possible," she said.


Ireland's CPR success story

In her presentation Hannon, who works as Resuscitation Training Officer at the Connolly Hospital Blanchardstown (CHB), Dublin, described Ireland's success story, where the "National First Responders campaign" set out to teach resuscitation to the general public.



Perhaps the most innovative part of the programme was the introduction of CPR training into the school curriculum. In the "CPR 4 Schools Programme", which ran in 2009, all Transition Year students (aged 16 years), amounting to around 27000 people, were issued with self training kits containing a DVD, booklet and inflatable manikin, which together create and easy to follow lesson in CPR. Teachers acted as facilitators to the training, rather than instructors.


"We showed that by targeting school children there was a real potential that they'll take the knowledge home and teach the rest of the family," said Hannon.


Future moves to establish a registry of automatic external defibrillators (AEDs) in Southern Ireland, she said, should further increase survival. "Once we know exactly where defibrillators are based we hope to link them to the ambulance services so that lay rescuers can be contacted to take them directly to the victim," said Hannon. An additional advantage, she added, would be that such knowledge would enable strategies to be put in place to ensure good maintenance of the devices.

Can music help achieve the correct rate and depth in CPR?


"It's really important to use the correct amount of force to compress the heart sufficiently to push the blood out, and at the same time you need the correct rate of compressions to enable sufficient blood to reach the brain," said Rawlins, now a junior doctor at the Great Western Hospital, Swindon, UK.

"It's quite difficult to get the right rate even if someone shows you, and really easy to deskill if you haven't practiced for a while. The idea behind using popular music is that songs stay longer in your head," she said.

In a study published in the BMJ in 2009 , Rawlins and colleagues showed that using "Nellie the Elephant" as background music significantly increased the number of people getting the right rate of compressions on a manikin, but that there was a drop in those hitting the correct depth.

A second study, published in the Emergency Medical Journal in 2012 , found that the proportion of paramedics who maintained compressions within the optimal range of 100 to 120 a minute was significantly higher when listening to "Disco Science" by Mirwais (82%) than when listening to "Achy Breaky Heart" by Billy Ray Cyrus (64%) or no music at all (65%). But over a third of compressions were still too shallow, irrespective of the music used. "We found that "Achy Breaky Heart" was actually harmful because it made people compress too fast, so that the heart didn't have a chance to fill properly," said Rawlins. They did not, however, investigate "Stayin' Alive", by the Bee Gees, which the British Heart Foundation used in their 2012 "Hard and Fast" ad campaign.

At the end of the studies the investigators remained unconvinced that music provided any additional benefits in improving the quality of CPR compared with using a metronome. "We think the problem may be that music distracted people from focusing on the force of the compressions," explained Rawlins. In future, she said, it might be more effective to develop manikins with sensors for pressure and rate that could be attached to Wii Fit type devices to deliver real time feedback, and also to have smart phone aps that could be used to provide a metronome in emergency situations.


The latest guidelines from the European Resuscitation Council (ERC)4 and the American Heart Association, both updated 2010, emphasize that chest compressions are the most important action in resuscitation. The new drill goes that if someone is unresponsive and their breathing is noisy, infrequent or doesn't seem normal, after calling for an ambulance you should start hands only CPR. Here the technique involves pushing hard and fast at the centre of the casualty's chest, at a rate of two pushes per second to a depth of 5 to 6 cm (two inches).


While CPR alone is unlikely to restart the heart (treatment with high voltage electrical shocks, defibrillation, is needed to restore the normal heart rhythm), its main purpose is to restore flow of oxygenated blood to the brain and heart and extend the brief window for a successful resuscitation without permanent brain damage. Typically, blood contains five to seven minutes worth of oxygen and the effect of constant fast chest compressions is to keep that oxygen moving to the brain and other vital organs. "The idea of CPR is to buy valuable time before the defibrillator arrives," said Hannon. Guidelines additionally state that bystanders who are trained and willing should combine chest compressions with rescue breathing at a ratio of 30 compressions to two breaths. In children, since 70% of out of hospital cardiac arrests are asphyxia in origin, survival rates are better if they are provided with both chest compressions and ventilations. "But even here hands only CPR is better than nothing," stressed Hannon.


Contact: Jacqueline Partarrieu
European Society of Cardiology

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